El Paso County SPD Standard Medical EPO_Revised Jan 2013 PD

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El Paso County SPD Standard Medical EPO_Revised Jan 2013 PD

PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION

FOR

EL PASO COUNTY

STANDARD MEDICAL EPO

RESTATED: JANUARY 1, 2011

REVISED: JANUARY 1, 2013


TABLE OF CONTENTS

INTRODUCTION ....................................................................................................................................................... 1

SCHEDULE OF BENEFITS ...................................................................................................................................... 3

ELIGIBILITY, FUNDING, EFFECTIVE DATE AND TERMINATION PROVISIONS ........................................ 8

ENROLLMENT ........................................................................................................................................................ 10

MANDATORY COVERAGE .................................................................................................................................. 11

EFFECTIVE DATE .................................................................................................................................................. 14

TERMINATION OF COVERAGE .......................................................................................................................... 14

MEDICAL BENEFITS ............................................................................................................................................. 17

COVERED CHARGES ............................................................................................................................................ 17

WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA) ......................................................................... 29

COST MANAGEMENT SERVICES ....................................................................................................................... 30

COORDINATED CARE .......................................................................................................................................... 30

PRE-NOTIFICATION DETERMINATION AND REVIEW PROCESS ................................................................... 31

CASE MANAGEMENT ............................................................................................................................................ 31

CARELINK PRIORITY MATERNITY CARE ....................................................................................................... 32

DEFINED TERMS ................................................................................................................................................... 33

PLAN EXCLUSIONS ............................................................................................................................................... 38

HOW TO SUBMIT A CLAIM ................................................................................................................................. 42

CLAIMS REVIEW PROCEDURE ........................................................................................................................... 42

COORDINATION OF BENEFITS ........................................................................................................................... 46

THIRD PARTY RECOVERY PROVISION ............................................................................................................ 51

COBRA CONTINUATION COVERAGE ............................................................................................................... 52

RESPONSIBILITIES FOR PLAN ADMINISTRATION ........................................................................................ 58

HIPAA PRIVACY STANDARDS ........................................................................................................................... 59

HIPAA SECURITY STANDARDS ......................................................................................................................... 61

GENERAL PLAN INFORMATION ........................................................................................................................ 62


INTRODUCTION

This document is a description of El Paso County (the Plan). No oral interpretations can change this Plan. The Plan

described is designed to protect Plan Participants against certain catastrophic health expenses.

Coverage under the Plan will take effect for an eligible Employee and designated Dependents when the Employee

and such Dependents satisfy the Waiting Period and all the eligibility requirements of the Plan.

The Employer fully intends to maintain this Plan indefinitely. However, it reserves the right to terminate, suspend,

discontinue or amend the Plan at any time and for any reason.

Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums,

copayments, exclusions, limitations, definitions, eligibility and the like.

Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no

coverage at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan,

such as coordination of benefits, subrogation, exclusions, timeliness of COBRA elections, utilization review or other

cost management requirements, lack of Medical Necessity, lack of timely filing of claims or lack of coverage.

No action at law or in equity shall be brought to recover under any section of this Plan until the appeal rights provided

have been exercised and the Plan benefits requested in such appeals have been denied in whole or in part.

The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for

expenses incurred before coverage began or after coverage terminated. An expense for a service or supply is incurred

on the date the service or supply is furnished.

If the Plan is terminated, amended, or benefits are eliminated, the rights of Covered Persons are limited to Covered

Charges incurred before termination, amendment or elimination.

Grandfathered Plan. This Plan believes it is a "grandfathered health plan" under the Patient Protection and Affordable

Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve

certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan

means that the Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans.

However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what

might cause a plan to change from grandfathered health plan status, can be directed to the Plan Administrator . You may

also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1 (866) 444-3272 or the U.S.

Department of Health and Human Services at www.HealthCare.gov. This website has a table summarizing which

protections do and do not apply to grandfathered health plans.

This document summarizes the Plan rights and benefits for covered Employees and their Dependents and is divided

into the following parts:

Eligibility, Funding, Effective Date and Termination. Explains eligibility for coverage under the Plan, funding of

the Plan and when the coverage takes effect and terminates.

Schedule of Benefits. Provides an outline of the Plan reimbursement formulas as well as payment limits on certain

services.

Benefit Descriptions. Explains when the benefit applies and the types of charges covered.

Cost Management Services. Explains the methods used to curb unnecessary and excessive charges.

Defined Terms. Defines those Plan terms that have a specific meaning.

Plan Exclusions. Shows what charges are not covered.

El Paso County 1

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Standard Medical EPO


Claim Provisions. Explains the rules for filing claims.

Coordination of Benefits. Shows the Plan payment order when a person is covered under more than one plan.

Third Party Recovery Provision. Explains the Plan's rights to recover payment of charges when a Covered Person

has a claim against another person because of injuries sustained.

COBRA Continuation Coverage. Explains when a person's coverage under the Plan ceases and the continuation

options which are available.

El Paso County 2

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SCHEDULE OF BENEFITS

MEDICAL BENEFITS

All benefits described in this Schedule are subject to the exclusions and limitations described more fully herein

including, but not limited to, the Plan Administrator's determination that: care and treatment is Medically Necessary;

that charges are Usual and Reasonable; that services, supplies and care are not Experimental and/or Investigational.

The meanings of these capitalized terms are in the Defined Terms section of this document.

Pre-notification of certain services is strongly recommended, but not required by the Plan. Pre-notification provides

information regarding coverage before the Covered Person receives treatment, services or supplies. A benefit

determination on a Claim will be made only after the Claim has been submitted. A pre-notification of services by

CareLink is not a determination by the Plan that a Claim will be paid. All Claims are subject to the terms and

conditions, limitations and exclusions of the Plan at the time charges are incurred. A pre-notification is not required

as a condition precedent to paying benefits, and cannot be appealed.

Take Over Provision: If the following procedures were pre-approved prior to January 1, 2011, these

procedures will be considered Covered Charges under this Plan provided documentation is provided to the

Claims Administrator prior to these services being rendered:

o

o

o

o

o

Chemotherapy treatment

Transplant services

3 rd semester of Pregnancy

Morbid Obesity treatment

Out of Network treatment

Note: Any change in the plan of care, treatment, or modalities after the procedure had been initially preapproved

prior to January 1, 2011, will require a new approval by the Claims Administrator before the

procedure(s) will be considered a Covered Charge under this Plan.

This Plan has entered into an agreement with certain Hospitals, Physicians and other health care providers, which are

called Participating Providers. Because these Participating Providers have agreed to charge reduced fees to persons

covered under the Plan, the Plan can afford to reimburse a higher percentage of their fees.

This Plan will utilize the El Paso County Employee Health Center (“Clinic”) and the El Paso County Cofinity

Network for Plan Participants residing inside the Cofinity Network service area. For all Plan Participants residing

outside of the aforementioned service area, the Plan will utilize the First Health Network.

In order to receive benefits, all medical care must be provided by a Participating Provider. The use of non-

Participating Providers will not be eligible under this Plan, except when otherwise noted.

If the Covered Person’s Participating Provider Primary Care Physician or other Participating Provider determines the

Covered Person requires hospitalization, arrangements will need to be made for the Covered Person’s admission into

a Participating Provider Network Hospital.

Note: The Memorial Hospital System is NOT in the El Paso County Cofinity Network. Services provided at

Memorial Hospital in El Paso County will NOT be a Covered Charge unless they are emergent in nature or a Non-

Participating Provider authorization is obtained.

To access a list of Participating Providers, please refer to the El Paso County Employee Benefits Guidebook, the

Cofinity website, www.cofinity.net , the miBenefits website via www.ebms.com or contact the Cofinity customer

service toll-free @ 1 (800) 831-1166. For First Health Network Providers, please refer to the First Health Network

website, www.firsthealth.com, or contact the First Health Network customer service toll-free @ 1 (888) 685-7774.

El Paso County 3

Revised January 1, 2013

Standard Medical EPO


NON-PARTICIPATING PROVIDER AUTHORIZATION

If the Covered Person is unable to locate a Participating Provider in the specialty and/or for Medically Necessary

treatment/services that he/she is seeking, please contact CareLink at (866) 894-1505 in order to obtain a prior

authorization to use a Non-Participating Provider. Note: Documentation from the referring Physician, as to the

medical necessity to utilize a Non-Participating Provider specialist or other Non-Participating Provider or facility,

must be provided to CareLink before a Non-Participating Provider Authorization can be approved.

Failure to obtain authorization to utilize a Non-Participating Provider or facility will result in no

reimbursement from the Plan for services rendered.

Under the following circumstances, the Participating Provider payment benefit level will be made for certain

Non-Participating Provider services:

‣ Ancillary services, including radiology, pathology, anesthesiology, lab or assistant surgeon when provided by

a Non Participating Provider at a Participating Provider Network facility.

Prior to receiving medical care services, the Covered Person should confirm with the provider and the

Participating Provider Organization that the provider is a participant in this organization.

In rare instances, an inpatient Hospital stay (reimbursed on a Diagnostic Related Grouping (DRG) or per diem PPO

rate) can be repriced to exceed the billed amount. The Plan will be responsible for this overage.

Deductibles/Copayments payable by Plan Participants

Deductibles/Copayments are dollar amounts that the Covered Person must pay before the Plan pays.

A deductible is an amount of money that is paid once a Calendar Year per Covered Person. Typically, there is one

deductible amount per Plan and it must be paid before any money is paid by the Plan for any Covered Charges. Each

January 1st, a new deductible amount is required.

Deductibles do not accrue toward the 100% maximum out-of-pocket payment.

A copayment is the amount of money that is paid each time a particular service is used. Typically, there may be

copayments on some services and other services will not have any copayments.

Copayments do not accrue toward the 100% maximum out-of-pocket payment.

El Paso County 4

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STANDARD MEDICAL EPO BENEFITS SCHEDULE

PARTICIPATING

PROVIDERS

NON-PARTICIPATING

PROVIDERS

CALENDAR YEAR

ANNUAL BENEFIT AMOUNT

$2,000,000

DEDUCTIBLE, PER CALENDAR YEAR

Per Covered Person $2,000 Not Covered

Per Family Unit $6,000 Not Covered

MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR

Per Covered Person $6,000 Not Covered

Per Family Unit $10,000 Not Covered

The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which

time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated

otherwise.

The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%.

• Deductibles

• Copayments

COVERED CHARGES

Hospital Services

Inpatient Room and Board 75% after deductible and $500

copayment per admission based on the

semiprivate room rate

Intensive Care Unit 75% after deductible and $500

copayment per admission based on the

Hospital's ICU Charge

Outpatient Facility Services 75% after $250 copayment per visit

No deductible applies

Not Covered

Not Covered

Not Covered

Outpatient Physician services 75%, no deductible or copayment

applies

Note: The copayment will apply as long as services billed include one or more of the facility room charges:

Operating room, recovery room, procedures room, treatment room, and observation room.

Skilled Nursing Facility, 75% after deductible

Not Covered

Rehabilitation Hospital and the facility's semiprivate room rate

Sub-Acute Facilities

60 days maximum per Calendar Year

Emergency Room Services

(including ER Physician services)

Medical Emergency Care

Medical Non-Emergency Care

100% after $200 copayment per visit;

No deductible applies

Not Covered

Note: The ER copayment will be waived if admitted to the Hospital directly from the ER.

Urgent Care Services

100% after $100 copayment per visit;

No deductible applies

100% after $100 copayment per visit;

No deductible applies

Note: The Urgent Care copayment will be waived if admitted to the Hospital directly from Urgent Care.

El Paso County 5

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PARTICIPATING

PROVIDERS

NON-PARTICIPATING

PROVIDERS

Physician Services

Inpatient Services 75% after deductible Not Covered

El Paso County Employee Health 100% after $10 copayment per visit

Not Covered

Center (Clinic) Office Visit No deductible applies

Primary Care Physician (PCP)

Office Visit

100% after $50 copayment per visit

Not Covered

No deductible applies

Note: A Primary Care Physician (PCP) is defined as a general practitioner, family practitioner, general internist

(internist whose practice is 70% general medicine), Nurse Practitioner, Physician’s Assistant, or pediatrician.

An OB/GYN will be considered a specialist.

Specialist office visits 100% after $75 copayment per visit

No deductible applies

Surgery performed in the office 100% after $10 Clinic, $50 PCP or

(including any medical supplies $75 Specialist copayment per visit

and injections rendered during

the surgery)

No deductible applies

Injections (other than allergy) 100% after applicable Clinic, PCP or

Specialist office visit copayment

Allergy serum and injections

(including related office visit)

Preventive Care

Routine Well Care

(ages birth through adult)

No deductible applies

100%

No deductible or copayment will apply

100% after $10 Clinic copayment or

$40 copayment for all other providers

No deductible applies

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Includes: Routine office visits, routine physical examination, mammogram, gynecological exam, Pap smear, PSA,

routine lab and x-rays, routine colonoscopy, flexible sigmoidoscopy, and immunizations.

Ambulance Service

75% after deductible

Note: Pre-authorization with the Claims Administrator will be required for non-emergent transport.

Advanced Radiological Imaging 75%

Not Covered

(i.e., MRIs, MRAs, CAT Scans, No deductible or copayment will apply

PET Scans and Nuclear Medicine)

Diagnostic X-ray & Lab Testing 100%

No deductible or copayment will apply

Not Covered

Durable Medical Equipment 100%

Not Covered

No deductible or copayment will apply

Home Health Care

75% after deductible

Not Covered

60 days maximum per Calendar Year

Home Infusion Therapy 75% after deductible Not Covered

Hospice Care

75% after deductible

Not Covered

Bereavement Counseling 75% after deductible

Not Covered

Mental Disorders and Substance Abuse Treatment

Inpatient Services Payable as any other Illness Not Covered

Outpatient Visits

100% after $10 copayment

Not Covered

No deductible applies

Morbid Obesity Benefit Payable as any other Illness Not Covered

Note: A pre-authorization is required prior to services being rendered. Please see the Covered Charges section for

more information regarding this benefit.

El Paso County 6

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PARTICIPATING

PROVIDERS

NON-PARTICIPATING

PROVIDERS

Nutritional Evaluation Payable as any other Illness

Not Covered

3 visits per Calendar Year maximum

Note: Please see the Covered Charges section for more information regarding this benefit.

Outpatient Short-Term 100% after $20 copayment per visit

Not Covered

Rehabilitation Therapy and

Chiropractic Services

No deductible applies

60 days combined maximum per

Calendar Year

Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab, Cognitive

Therapy and Chiropractic services.

Multiple services provided on the same day constitute one day, but a separate copayment will apply to the services

provided by each Physician.

The Outpatient Short Term Rehab copay does not apply to services provided as part of a Home Health Care visit.

Therapy sessions provided in the home will accumulate to the benefit maximum.

Orthotics 100%

Not Covered

No deductible or copayment will apply

Note: See Covered Charges section for details.

Ostomy Supplies

100%, no deductible applies

Prosthetics 100%

Not Covered

No deductible or copayment will apply

Pregnancy

Initial visit

(to confirm Pregnancy)

All subsequent prenatal visits,

postnatal visits, and Physician’s

delivery charges (i.e., global

maternity fee)

Physician’s office visits in

addition to the global maternity

fee (when performed by an

OB/GYN or specialist)

Delivery – Facility charges

(Inpatient Hospital, Birthing

Center)

Organ Transplants

100% after $75 Specialist office visit

copayment

75% after deductible

100% after $75 office visit copayment

No deductible applies

Payable per Inpatient Hospitalization

benefit

Payable as any other Illness

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Transportation Benefit Maximum $10,000 Lifetime Maximum

Note: See the Covered Charges section for more information regarding this benefit.

Renal Dialysis Services

(will be payable subject to 200%

75% after deductible

of the Medicare equivalent rate)

Note: Please see the COVERED CHARGES section for additional information regarding this benefit.

Wigs

75% after deductible

$1,000 Lifetime Maximum

Note: Limited to the initial purchase of a wig when deemed Medically Necessary due to temporary or permanent

hair loss. See the Covered Charges section for more information regarding this benefit.

All Other Eligible Charges 75% after deductible Not Covered

El Paso County 7

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ELIGIBILITY, FUNDING, EFFECTIVE DATE

AND TERMINATION PROVISIONS

A Plan Participant should contact the Claims Administrator to obtain additional information, free of charge, about

Plan coverage of a specific benefit, particular drug, treatment, test or any other aspect of Plan benefits or

requirements.

ELIGIBILITY

Eligible Classes of Employees.

• All Full-Time, Active or Job Share Employees of the Employer

• Pre-Medicare Eligible Retirees

Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage from the first day

that he or she:

(1) is a Full-Time, Active Employee or a Job Share Employee of the Employer. An Employee is considered

to be Full-Time if he or she normally works at least 40 hours per week (37.5 hours per week for District

Attorney’s office staff) and is on the regular payroll of the Employer for that work.

A “Job-Share Employee” is defined as an Employee who is sharing a full-time position with another Job-

Share Employee. Typically, a Job-Share Employee works an average of 20 hours per week; however, the

hours worked may be split in a different manner for a total of 40 hours between the two Job-Share

Employees; or

(2) is a pre-Medicare eligible Retiree.

In order to be eligible for continued coverage under this Plan as a pre-Medicare eligible Retiree; the

covered Employee must meet the following requirements at the time of retirement from the Employer:

• Meets all requirements as set forth by El Paso County Benefits and Retirement office;

• Be actively enrolled under the Plan at the time of retirement; and

• Must complete and sign an enrollment form electing to continue coverage under the Plan as a Pre-

Medicare eligible Retiree; and

(3) is in a class eligible for coverage; and

(4) completes the employment Waiting Period as follows:

a) If the Employee is hired full-time from the 1st through the 15th of the month, coverage will

become effective on the first day of the next calendar month; or

b) If the Employee is hired full-time starting the 16th through the last day of the month, coverage

will become effective the first day of the second following month as an Active Employee.

A "Waiting Period" is the time between the first day of employment as an eligible Employee and the

first day of coverage under the Plan; and

(5) per Federal guidelines, all Employees and their covered Dependents must provide his/her social security

number at the time of enrollment under this Plan.

Upon retirement, an Employee can choose between COBRA Continuation Coverage or continuing under the

terms of the Plan as a pre-Medicare eligible Retiree if he/she satisfies the criteria as set forth above.

El Paso County 8

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Standard Medical EPO


If the Employee is eligible and chooses to continue coverage under the terms of the Plan as a pre-Medicare eligible

Retiree, he or she will forfeit his or her right to elect COBRA Continuation Coverage at a later date.

In the event the Employee chooses to continue under the terms of the Plan as a pre-Medicare eligible Retiree, the

Employee and his or her Spouse and Dependent children, who are active Plan Participants at the time of the

Employee’s retirement with the Employer, may remain eligible for coverage up to the limitations as stated under

the Plan, providing enrollment is made on a timely basis as defined in the section “Timely Enrollments” in the

Enrollment section under this Plan.

Eligible Classes of Dependents. A Dependent is any one of the following persons:

(1) A covered Employee's Spouse, a covered Retiree’s Spouse, or a deceased Retiree’s Spouse, and

children from birth to the limiting age of 26 years. When a child reaches the limiting age, coverage will

end on the last day of the child’s birthday month.

The term "Spouse" shall mean a person of the opposite sex recognized as the covered Employee's

husband or wife. The Plan Administrator may require documentation proving a legal marital relationship.

The term "children" shall include natural children, adopted children, children placed with a covered

Employee in anticipation of adoption, or step-children.

The phrase "child placed with a covered Employee in anticipation of adoption" refers to a child

whom the Employee intends to adopt, whether or not the adoption has become final, who has not

attained the age of 18 as of the date of such placement for adoption. The term "placed" means the

assumption and retention by such Employee of a legal obligation for total or partial support of the child

in anticipation of adoption of the child. The child must be available for adoption and the legal process

must have commenced.

Any child of a Plan Participant who is an alternate recipient under a Qualified Medical Child Support

Order (QMCSO) shall be considered as having a right to Dependent coverage under this Plan. A

participant of this Plan may obtain, without charge, a copy of the procedures governing QMCSO

determinations from the Plan Administrator.

The Plan Administrator may require documentation proving dependency, including birth certificates,

tax records or initiation of legal proceedings severing parental rights.

Premium payments for Dependent health insurance are usually exempt from federal income tax.

Generally, if the covered Employee can claim an individual as a Dependent for purposes of federal

income tax, then the premium for that Dependent’s health insurance coverage will not be taxable to the

covered Employee as income. However, in the rare instance that the covered Employee does cover an

individual under his/her health insurance who does not meet the federal definition of a Dependent, the

premium may be taxable to the covered Employee as income. For further questions and information,

please consult a tax consultant or attorney.

(2) A covered Dependent child who reaches the limiting age and is Totally Disabled and is incapable of

self-sustaining employment by reason of mental or physical handicap. The Plan Administrator may

require, at reasonable intervals during the two years following the Dependent's reaching the limiting age,

subsequent proof of the child's Total Disability and dependency.

After such two-year period, the Plan Administrator may require subsequent proof not more than once

each year. The Plan Administrator reserves the right to have such Dependent examined by a Physician of

the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity.

These persons are excluded as Dependents: other individuals living in the covered Employee's home, but who are

not eligible as defined; the divorced former Spouse of the Employee; foster children; or any person who is covered

under the Plan as an Employee.

El Paso County 9

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If a person covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the

person is covered continuously under this Plan before, during and after the change in status, credit will be given for

deductibles and all amounts applied to maximums.

If both mother and father are Employees, their children may be covered as Dependents of the mother or

father, but not of both.

Eligibility Requirements for Dependent Coverage. A family member of an Employee will become eligible for

Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member

satisfies the requirements for Dependent coverage.

At any time, the Plan may require proof that a Spouse or a child qualifies or continues to qualify as a Dependent as

defined by this Plan.

FUNDING

Cost of the Plan. El Paso County shares the cost of Employee and Dependent coverage under this Plan with the

covered Employees.

The level of any Employee contributions is set by the Plan Administrator. The Plan Administrator reserves the right

to change the level of Employee contributions.

Please refer to the El Paso County Employee Benefits Guide Book for information regarding the cost of Employee

and Dependent coverage under this Plan.

Please refer to the El Paso County Retiree Benefits Guide Book for information regarding the cost of Retiree and

Dependent coverage under this Plan.

ENROLLMENT

Enrollment Requirements.

An Employee must enroll for coverage by filling out and signing an enrollment application along with or applying

online providing an appropriate payroll deduction authorization. If Dependent coverage is desired, the Employee will

be required to enroll his/her Dependents.

Enrollment Requirements for Newborn Children.

A newborn child of a covered Employee will become insured for Medical Insurance on the date of his birth for only

the initial thirty-one (31) day period. In order to continue coverage beyond this thirty-one (31) day period, the

newborn child must be enrolled in this Plan on a timely basis, as defined in the section “Timely Enrollment” below or

the enrollment will be considered a Late Enrollment, there will be no further payment from the Plan and the parents

will be responsible for all expenses incurred beyond this initial thirty-one (31) day period.

TIMELY, LATE OR OPEN ENROLLMENT

(1) Timely Enrollment - The enrollment will be "timely" if the completed form is received by the Plan

Administrator no later than thirty-one (31) days after the person becomes eligible for the coverage, either

initially or under a Special Enrollment Period.

If two Employees (husband and wife) are covered under the Plan and the Employee who is covering the

Dependent children terminates coverage, the Dependent coverage may be continued by the other covered

Employee with no Waiting Period as long as coverage has been continuous.

(2) Late Enrollment - An enrollment is "late" if it is not made on a "timely basis" or during a Special

Enrollment Period. Late Enrollees and their Dependents who are not eligible to join the Plan during a

Special Enrollment Period may join only during open enrollment.

El Paso County 10

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Standard Medical EPO


If an individual loses eligibility for coverage as a result of terminating employment, a reduction of hours,

or a general suspension of coverage under the Plan then upon becoming eligible again due to resumption

of employment or due to resumption of Plan coverage, only the most recent period of eligibility will be

considered for purposes of determining whether the individual is a Late Enrollee.

The time between the date a Late Enrollee first becomes eligible for enrollment under the Plan and the

first day of coverage is not treated as a Waiting Period. Coverage begins as stated in the Open

Enrollment section.

(3) Open Enrollment - Each year there is an annual open enrollment period designated by the Employer

during which covered Employees may change their benefit elections under the Plan, and a covered

Employee may add or drop coverage for their Dependents.

Benefit choices made during the open enrollment period will take effect January 1 st following the open

enrollment period.

Benefit choices made during the open enrollment period will remain in effect until the next open

enrollment period unless there is a Special Enrollment event or a change in family status during the year

(birth, death, marriage, divorce, adoption) or loss of coverage due to loss of a Spouse's employment. To

the extent previously satisfied, coverage Waiting Periods and Pre-Existing Conditions Limits will be

considered satisfied when changing from one benefit option under the Plan to another benefit option

under the Plan.

A Plan Participant may automatically retain his or her present coverages. Plan Participants will receive

detailed information regarding open enrollment from their Employer.

MANDATORY COVERAGE

It is a condition of employment that Full-Time Employees enroll in an El Paso County medical benefit plan or

provide evidence of other current coverage through another entity. If the Employee does not have or maintain this

required medical coverage, he/she may be automatically enrolled by the Employer into an El Paso County medical

benefit plan and may be required to pay any required premiums for this coverage. The effective date of coverage may

be the latter of the initial eligibility date of coverage or the last date of verifiable coverage. The Employee’s

Dependents will not be allowed to enroll during this time and will have to wait until the next following Open

Enrollment opportunity or Special Enrollment Period, if applicable.

SPECIAL ENROLLMENT RIGHTS

Federal law provides Special Enrollment provisions under some circumstances. If an Employee is declining

enrollment for himself or his dependents (including their spouse) because of other health insurance or group health

plan coverage, there may be a right to enroll in this Plan if there is a loss of eligibility for that other coverage (or if the

employer stops contributing towards the other coverage or coinciding with an open enrollment period specific to the

other coverage). However, a request for enrollment must be made within thirty-one (31) days after the coverage ends

(or after the employer stops contributing towards the other coverage).

Note: A pre-Medicare eligible Retiree who declines continued coverage at retirement and later loses other coverage

will not be entitled to a Special Enrollment right, nor will their Dependent children.

In addition, in the case of a birth, marriage, adoption or placement for adoption, there may be a right to enroll in this

Plan. However, a request for enrollment must be made within thirty-one (31) days after the birth, marriage, adoption

or placement for adoption.

The Special Enrollment rules are described in more detail below. To request Special Enrollment or obtain

more detailed information of these portability provisions, contact the Plan Administrator.

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SPECIAL ENROLLMENT PERIODS

The Enrollment Date for anyone who enrolls under a Special Enrollment Period is the first date of coverage. Thus, the

time between the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of

coverage is not treated as a Waiting Period. (Note: A pre-Medicare eligible Retiree who declines continued coverage

at retirement and later loses other coverage will not be entitled to a Special Enrollment right, nor will their

Dependent children.)

(1) Individuals losing other coverage creating a Special Enrollment right. An Employee or Dependent

who is eligible, but not enrolled in this Plan, may enroll if loss of eligibility for coverage meets all of the

following conditions:

(Note: The following provisions will not be applicable to pre-Medicare eligible Retirees or their Spouses

and Dependent children.)

(a)

(b)

(c)

(d)

The Employee or Dependent was covered under a group health plan or had health insurance

coverage at the time coverage under this Plan was previously offered to the individual.

If the Employee provided proof of other coverage at the time that coverage was offered and that

the other health coverage was the reason for declining enrollment.

The coverage of the Employee or Dependent who had lost the coverage was under COBRA and

the COBRA coverage was exhausted, or was not under COBRA and either the coverage was

terminated as a result of loss of eligibility for the coverage or because employer contributions

towards the coverage were terminated.

The Employee or Dependent requests enrollment in this Plan not later than 31 days after the date

of exhaustion of COBRA coverage or the termination of non-COBRA coverage due to loss of

eligibility or termination of employer contributions, described above.

For purposes of these rules, a loss of eligibility occurs if one of the following occurs:

(i)

(ii)

(iii)

(iv)

The Employee or Dependent has a loss of eligibility due to the plan no longer offering any

benefits to a class of similarly situated individuals (i.e., part-time employees).

The Employee or Dependent has a loss of eligibility as a result of legal separation, divorce,

cessation of dependent status (such as attaining the maximum age to be eligible as a dependent

child under the plan), death, termination of employment, or reduction in the number of hours of

employment or contributions towards the coverage were terminated.

The Employee or Dependent has a loss of eligibility when coverage is offered through an HMO,

or other arrangement, in the individual market that does not provide benefits to individuals who

no longer reside, live or work in a service area, (whether or not within the choice of the

individual).

The Employee or Dependent has a loss of eligibility when coverage is offered through an HMO,

or other arrangement, in the group market that does not provide benefits to individuals who no

longer reside, live or work in a service area, (whether or not within the choice of the individual),

and no other benefit package is available to the individual.

(2) Dependent beneficiaries. If:

(a)

(b)

The Employee is a participant under this Plan (or has met the Waiting Period applicable to

becoming a participant under this Plan and is eligible to be enrolled under this Plan but for a

failure to enroll during a previous enrollment period), or

The pre-Medicare eligible Retiree is a participant under this Plan; and

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(c)

A person becomes a Dependent of the Employee or pre-Medicare eligible Retiree through

marriage, birth, adoption or placement for adoption,

then the Dependent (and if not otherwise enrolled, the Employee) may be enrolled under this Plan. In the

case of the birth or adoption of a child, the Spouse of the covered Employee may be enrolled as a

Dependent of the covered Employee if the Spouse is otherwise eligible for coverage.

In the case of marriage, birth, adoption or placement for adoption, the Spouse or Dependent of a

covered pre-Medicare eligible Retiree may be enrolled as a Spouse or Dependent of the covered pre-

Medicare eligible Retiree if the Spouse or Dependent is otherwise eligible for coverage under the Plan.

If the Employee is not enrolled at the time of the event, the Employee must enroll under this Special

Enrollment Period in order for his eligible Dependents to enroll. If the pre-Medicare eligible Retiree is

not enrolled at the time of the event, this Special Enrollment right will not be applicable.

The Dependent Special Enrollment Period is a period of 31 days and begins on the date of the marriage,

birth, adoption or placement for adoption. To be eligible for this Special Enrollment, the Dependent

and/or Employee must request enrollment during this 31-day period.

The coverage of the Dependent and/or Employee or pre-Medicare eligible Retiree enrolled in the Special

Enrollment Period will be effective:

(a)

(b)

(c)

in the case of marriage, as of the date of marriage or beginning the first day of the calendar month

following the date of marriage;

in the case of a Dependent's birth, as of the date of birth; or

in the case of a Dependent's adoption or placement for adoption, the date of the adoption or

placement for adoption.

Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA)

Employees and their Dependents who are otherwise eligible for coverage under the Plan but who are not enrolled can

enroll in the Plan provided that they request enrollment in writing within sixty (60) days from the date of the

following loss of coverage or gain in eligibility:

(a)

(b)

The eligible person ceases to be eligible for Medicaid or Children’s Health Insurance Program (CHIP)

coverage; or

The eligible person becomes newly eligible for a premium subsidy under Medicaid or CHIP.

If eligible, the Dependent (and, if not otherwise enrolled, the Employee) may be enrolled under this Plan.

This Dependent Special Enrollment Period is a period of 60 days and begins on the date of the loss of coverage

under the Medicaid or CHIP plan OR on the date of the determination of eligibility for a premium subsidy under

Medicaid or CHIP. To be eligible for this Special Enrollment, the Employee must request enrollment in writing

during this 60-day period. The effective date of coverage will begin the first day of the first calendar month

following the date of loss of coverage or gain in eligibility.

If a State in which the Employee lives offers any type of subsidy, this Plan shall also comply with any other State

laws as set forth in statutes enacted by State legislature and amended from time to time, to the extent that the State

law is applicable to the Plan, the Employer and its Employees.

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EFFECTIVE DATE

Effective Date of Employee Coverage. An Employee will be covered under this Plan as outlined under the separate

Eligibility Requirements for Employee Coverage provision (refer to the “Eligibility” section under this Plan), when

the Employee satisfies all of the following:

(1) The Eligibility Requirements.

(2) The Enrollment Requirements of the Plan.

Effective Date of Dependent Coverage. A Dependent's coverage will take effect on the day that the Eligibility

Requirements are met; the Employee is covered under the Plan; and all Enrollment Requirements are met.

TERMINATION OF COVERAGE

When coverage under this Plan stops, Plan Participants will receive a certificate that will show the period of

Creditable Coverage under this Plan. The Claims Administrator maintains written procedures that explain how to

request this certificate. Please contact the Claims Administrator for a copy of these procedures and further details.

The Employer or Plan has the right to rescind any coverage of the Employee, pre-Medicare eligible Retiree

and/or Dependents for cause, making a fraudulent claim or an intentional material misrepresentation in

applying for or obtaining coverage, or obtaining benefits under the Plan. The Employer or Plan may either

void coverage for the Employee, pre-Medicare eligible Retiree and/or covered Dependents for the period of

time coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion,

or may immediately terminate coverage. The employer will refund all contributions paid for any coverage

rescinded; however, claims paid will be offset from this amount. The employer reserves the right to collect

additional monies if claims are paid in excess of the Employee's or pre-Medicare eligible Retiree and/or

Dependent's paid contributions.

When Employee Coverage Terminates. Employee coverage will terminate on the earliest of these dates:

(1) The date the Plan is terminated;

(2) The date the covered Employee's Eligible Class is eliminated;

(3) The last day of the calendar month in which the covered Employee ceases to be in one of the Eligible

Classes. This includes death or termination of Active Employment of the covered Employee. (See the

section entitled COBRA Continuation Coverage.) It also includes an Employee on disability leave of

absence or other leave of absence, unless the Plan specifically provides for continuation during these

periods;

(4) The end of the period for which the required contribution has been paid if the charge for the next period

is not paid when due. In the event of late or non-payment of health premiums, coverage will be

terminated retroactively to the last day coverage was paid in full. Health benefits will not be reinstated if

payment has not been received in full by the end of the 30-day grace period;

(5) If an Employee commits fraud or makes an intentional material misrepresentation in applying for or

obtaining coverage, or obtaining benefits under the Plan, then the Employer or Plan may either void

coverage for the Employee and covered Dependents for the period of time coverage was in effect, may

terminate coverage as of a date to be determined at the Plan's discretion, or may immediately terminate

coverage; or

(6) As otherwise stated in the Eligibility section.

Note: Except in certain circumstances, a covered Employee may be eligible for COBRA continuation coverage. For a

complete explanation of when COBRA continuation coverage is available, what conditions apply and how to select it,

see the section entitled COBRA Continuation Coverage.

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Continuation During Periods of Employer-Certified Disability, Leave of Absence or Temporary Layoff. A

person may remain eligible for a limited time if Active, full-time work ceases due to disability, leave of absence or

layoff. This continuance will end as follows:

For disability leave only: If a covered Employee’s Active service ends and he/she is approved for coverage

under the Employer’s Short-Term Disability (STD) policy the Employee will remain eligible while he/she is

continuously covered under the Employer’s STD policy. However, the Employee’s coverage will not continue

past the date coverage under the Employer’s STD policy ends.

For leave of absence or temporary layoff only: the end of the sixty (60) day period that next follows the date

on which the person last worked as an Active Employee.

While continued, coverage will be that which was in force on the last day worked as an Active Employee. However,

if benefits reduce for others in the class, they will also reduce for the continued person.

Continuation During Family and Medical Leave. Regardless of the established leave policies mentioned above,

this Plan shall at all times comply with the Family and Medical Leave Act of 1993 (FMLA) as promulgated in

regulations issued by the Department of Labor, if, in fact, FMLA is applicable to the Employer and all of its

Employees and locations. This Plan shall also comply with any other State leave laws as set forth in statutes enacted

by State legislature and amended from time to time, to the extent that the State leave law is applicable to the

Employer and all of its Employees. Leave taken pursuant to any other State leave law shall run concurrently with

leave taken under FMLA, to the extent consistent with applicable law.

If applicable, during any leave taken under the FMLA and/or other State leave law, the Employer will maintain

coverage under this Plan on the same conditions as coverage would have been provided if the covered Employee had

been continuously employed during the entire leave period.

If Plan coverage terminates during the FMLA, coverage will be reinstated for the Employee and his or her covered

Dependents if the Employee returns to work in accordance with the terms of the FMLA and/or other State leave law.

Coverage will be reinstated only if the person(s) had coverage under this Plan when the FMLA leave started, and will

be reinstated to the same extent that it was in force when that coverage terminated.

Rehiring a Terminated Employee. A terminated Employee who is rehired within thirty (30) days from the date of

termination will not be required to re-satisfy the employment Waiting Period. Otherwise, a terminated Employee who

is rehired after thirty (30) days from the date of termination will be treated as a new hire and will be required to

satisfy all Eligibility and Enrollment requirements as stated under this Plan.

Employees on Military Leave. Employees going into or returning from military service may elect to continue Plan

coverage as specified by the El Paso County Policies and Procedures Manual. These rights apply only to Employees

and their Dependents covered under the Plan immediately before leaving for military service.

(1) The maximum period of coverage of a person and the person's Dependents under such an election shall

begin on the date which the person’s absence begins and end on the date defined by the El Paso County

Policies and Procedures Manual.

(2) An Employee must make written application to the EBMS Department within 30 days of military leave

commencement in order to be eligible for continuation of coverage. If written application is not made,

coverage will end on the last day of the month in which the military service began.

(3) A person who elects to continue health plan coverage must pay premiums in accordance with the El Paso

County Policies and Procedures Manual.

This Plan shall at all times comply with the Uniformed Services Employment and Reemployment Rights Act

(USERRA), as amended from time to time. If the Employee has continuation rights under USERRA, the Employee

must meet the same requirements for electing USERRA coverage as are required for electing COBRA continuation

coverage. Coverage elected under these circumstances is concurrent, not cumulative. Only the Employee has election

rights under USERRA. Dependents do not have election rights under USERRA.

El Paso County 15

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If a pre-Medicare Eligible Retiree Coverage Terminates. Pre-Medicare eligible Retiree coverage will terminate on

the earliest of these dates:

(1) The date the Plan is terminated;

(2) The date the pre-Medicare eligible Retiree’s Eligible Class is eliminated;

(3) The last day of the calendar month in which the covered pre-Medicare eligible Retiree becomes eligible

for Medicare benefits whether or not he or she has enrolled in Medicare under Part A, Part B or both.

(4) The date of the pre-Medicare eligible Retiree’s death.

(5) The end of the period for which the required contribution has been paid if the charge for the next period

is not paid when due. In the event of late or non-payment of health premiums, coverage will be

terminated retroactively to the last day coverage was paid in full. Health benefits will not be reinstated if

payment has not been received in full by the end of the 30-day grace period;

(6) If an pre-Medicare eligible Retiree commits fraud or makes an intentional material misrepresentation in

applying for or obtaining coverage, or obtaining benefits under the Plan, then the Employer or Plan may

either void coverage for the pre-Medicare eligible Retiree and covered Dependents for the period of time

coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or

may immediately terminate coverage; or

(7) As otherwise stated in the Eligibility section.

When Dependent Coverage Terminates. A Dependent's coverage will terminate on the earliest of these dates:

(1) The date the Plan or Dependent coverage under the Plan is terminated;

(2) The date that the Employee's coverage under the Plan terminates for any reason including death. (See the

section entitled COBRA Continuation Coverage.);

(3) The last day of the calendar month in which the covered pre-Medicare eligible Retiree’s Spouse becomes

eligible for Medicare benefits whether or not he or she has enrolled in Medicare under Part A, Part B or both.

(4) The last day of the calendar month in which a covered Spouse or pre-Medicare eligible Retiree’s Spouse

loses coverage due to loss of dependency status. (See the section entitled COBRA Continuation

Coverage.);

(5) The last day of the birthday month in which a Dependent child reaches the limiting age as defined by the

Plan;

(6) The end of the period for which the required contribution has been paid if the charge for the next period

is not paid when due. In the event of late or non-payment of health premiums, coverage will be

terminated retroactively to the last day coverage was paid in full. Health benefits will not be reinstated if

payment has not been received in full by the end of the 30-day grace period;

(7) If a Dependent commits fraud or makes an intentional material misrepresentation in applying for or

obtaining coverage, or obtaining benefits under the Plan, then the Employer or Plan may either void

coverage for the Dependent for the period of time coverage was in effect, may terminate coverage as of a

date to be determined at the Plan's discretion, or may immediately terminate coverage; or

(8) As otherwise stated in the Eligibility section.

Note: Except in certain circumstances, a covered Dependent may be eligible for COBRA continuation coverage. For

a complete explanation of when COBRA continuation coverage is available, what conditions apply and how to select

it, see the section entitled COBRA Continuation Coverage.

El Paso County 16

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MEDICAL BENEFITS

Medical Benefits apply when Covered Charges are incurred by a Covered Person for care of an Injury or Sickness

and while the person is covered for these benefits under the Plan.

DEDUCTIBLE

Deductible Amount. This is an amount of Covered Charges for which no benefits will be paid. Before benefits can

be paid in a Calendar Year a Covered Person must meet the deductible shown in the Schedule of Benefits.

This amount will not accrue toward the 100% maximum out-of-pocket payment.

Family Unit Limit. When the maximum amount shown in the Schedule of Benefits has been incurred by members of

a Family Unit toward their Calendar Year deductibles, the deductibles of all members of that Family Unit will be

considered satisfied for that year.

BENEFIT PAYMENT

Each Calendar Year, benefits will be paid for the Covered Charges of a Covered Person that are in excess of the

deductible and any copayments. Payment will be made at the rate shown under reimbursement rate in the Schedule of

Benefits. No benefits will be paid in excess of the Maximum Benefit Amount or any listed limit of the Plan.

OUT-OF-POCKET LIMIT

Covered Charges are payable at the percentages shown each Calendar Year until the out-of-pocket limit shown in the

Schedule of Benefits is reached. Then, Covered Charges incurred by a Covered Person will be payable at 100%

(except for the charges excluded including deductibles and copayments) for the rest of the Calendar Year.

When a Family Unit reaches the out-of-pocket limit, Covered Charges for that Family Unit will be payable at 100%

(except for the charges excluded including deductibles and copayments) for the rest of the Calendar Year.

CALENDAR YEAR ANNUAL BENEFIT AMOUNT

The Calendar Year Annual Benefit Amount is shown in the Schedule of Benefits. It is the total amount of benefits

that will be paid under the Plan for all Covered Charges incurred by a Covered Person in a Calendar Year.

COVERED CHARGES

Covered Charges are the Usual and Reasonable Charges that are incurred for the following items of service and

supply. These charges are subject to the benefit limits, exclusions and other provisions of this Plan. A charge is

incurred on the date that the service or supply is performed or furnished.

(1) Hospital Care. The medical services and supplies furnished by a Hospital or Ambulatory Surgical

Center or a Birthing Center. Covered Charges for room and board will be payable as shown in the

Schedule of Benefits. After 23 observation hours, a confinement will be considered an inpatient

confinement.

Room charges made by a Hospital having only private rooms will be payable at the average private room

rate of that facility.

Charges for an Intensive Care Unit stay are payable as described in the Schedule of Benefits.

(2) Coverage of Pregnancy. The Usual and Reasonable Charges for the care and treatment of Pregnancy

are covered the same as any other Sickness.

Color / 3-D Ultrasounds will not be a Covered Charge under this benefit.

Group health plans generally may not, under Federal law, restrict benefits for any hospital length of stay

in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal

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delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not

prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging

the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and

issuers may not, under Federal law, require that a provider obtain authorization from the plan or the

issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

(3) Skilled Nursing Facility Care. The room and board and nursing care furnished by a Skilled Nursing

Facility will be payable up to the limits as stated in the Schedule of Benefits if and when:

(a)

(b)

(c)

the patient is confined as a bed patient in the facility; and

the attending Physician certifies that the confinement is Medically Necessary; and

the attending Physician completes a treatment plan which includes a diagnosis, the proposed

course of treatment and the projected date of discharge from the Skilled Nursing Facility.

(4) Physician Care. The professional services of a Physician for surgical or medical services.

Charges for multiple surgical procedures will be a Covered Charge subject to the following provisions:

(a)

(b)

If bilateral or multiple surgical procedures are performed by one (1) surgeon, benefits will be

determined based on the Usual and Reasonable Charge that is allowed for the primary

procedures; 50% of the Usual and Reasonable Charge will be allowed for each additional

procedure performed through the same incision or during the same operative session. Any

procedure that would not be an integral part of the primary procedure or is unrelated to the

diagnosis will be considered "incidental" and no benefits will be provided for such procedures;

If multiple unrelated surgical procedures are performed by two (2) or more surgeons on separate

operative fields, benefits will be based on the Usual and Reasonable Charge for each surgeon's

primary procedure. If two (2) or more surgeons perform a procedure that is normally performed

by one (1) surgeon, benefits for all surgeons will not exceed the Usual and Reasonable

percentage allowed for that procedure; and

(c) If an assistant surgeon is required, the assistant surgeon's Covered Charge will not exceed 20%

of the surgeon's Usual and Reasonable allowance.

(5) Private Duty Nursing Care. The private duty nursing care by a licensed nurse (R.N., L.P.N. or L.V.N.).

Covered Charges for this service will be included to this extent:

(a)

(b)

Inpatient Nursing Care. Charges are covered only when care is Medically Necessary or not

Custodial in nature and the Hospital's Intensive Care Unit is filled or the Hospital has no

Intensive Care Unit.

Outpatient Nursing Care. Charges are covered only when care is Medically Necessary and not

Custodial in nature. The only charges covered for Outpatient nursing care are those shown

below, under Home Health Care Services and Supplies. Outpatient private duty nursing care on

a 24-hour-shift basis is not covered.

(6) Home Health Care Services and Supplies. Charges for home health care services and supplies are

covered only for care and treatment of an Injury or Illness, and will be payable up to the limits as stated

in the Schedule of Benefits. The diagnosis, care and treatment must be certified by the attending

Physician and be contained in a Home Health Care Plan.

A home health care visit will be considered a periodic visit by either a nurse or therapist, as the case may

be, or four hours of home health aide services.

Outpatient private duty nursing will be a Covered Charge when deemed Medically Necessary.

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(7) Hospice Care Services and Supplies. Charges for hospice care services and supplies are covered only

when the attending Physician has diagnosed the Covered Person's condition as being terminal,

determined that the person is not expected to live more than six months and placed the person under a

Hospice Care Plan.

Covered Charges for Hospice Care Services and Supplies are payable as described in the Schedule of

Benefits.

The following charges for Hospice Care will not be covered under the Plan:

• The services of a person who is a member of the Covered Person’s family or who normally

resides in the Covered Person’s house;

• For any period when the Covered Person is not under the care of a Physician;

• For services or supplies not listed or defined under Hospice Care Services and Supplies;

• For any curative or life-prolonging procedures;

• To the extent that any other benefits are payable for those expenses under the Plan; or

• For services or supplies that are primarily to aid the Covered Person in daily living.

Bereavement counseling services by a licensed social worker or a licensed pastoral counselor for the

patient's immediate family (covered Spouse and/or covered Dependent Children). Bereavement services

must be furnished within six (6) months after the patient's death.

(8) Other Medical Services and Supplies. These services and supplies not otherwise included in the items

above are covered as follows:

(a)

(b)

(c)

Allergy testing, serum and injections.

Ambulance. Local Medically Necessary professional land or air ambulance service. A charge

for this item will be a Covered Charge only if the service is to the nearest Hospital or Skilled

Nursing Facility where necessary treatment can be provided unless the Plan Administrator finds

a longer trip was Medically Necessary.

Anesthetic; oxygen; blood and blood derivatives that are not donated or replaced; intravenous

injections and solutions. Administration of these items is included.

The following will not be a Covered Charge under this Plan:

Fees associated with the collection or donation of blood or blood products, except for autologous

donation in anticipation of scheduled services where in the attending Physician’s opinion the

likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.

(d)

Chemotherapy or radiation treatment with radioactive substances. The materials and services

of technicians are included.

Pre-notification of services, by the Plan Participant, for cancer treatment services is strongly

recommended. The pre-notification request to the Claims Administrator should include the

Covered Person’s plan of care and treatment protocol. Pre-notification of services should occur

at least seven (7) days prior to the initiation of treatment.

For pre-notification of services, call the Claims Administrator at the following numbers:

Toll Free in the United States: (800) 777-3575

Local Call in Billings, Montana: (406) 245-3575

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A pre-notification of services by the Claims Administrator is not a determination by the Plan

that claims will be paid. All claims are subject to the provisions of the Plan, including but not

limited to medical necessity, exclusions and limitations in effect when charges are incurred. A

pre-notification is not required as a condition to paying benefits, and cannot be appealed.

(e)

(f)

Circumcision. Care, treatment, services and supplies in connection with circumcision when

performed for a newborn child after Hospital discharge after birth.

Clinical Trials. Covered Charges will include charges made for routine patient services

associated with cancer clinical trials approved and sponsored by the federal government. In

addition the following criteria must be met:

• The cancer clinical trial is listed on the NIH web site www.clinicaltrials.gov as being

sponsored by the federal government;

• The trial investigates a treatment for terminal cancer and:

(i)

the person has failed standard therapies for the disease;

(ii) cannot tolerate standard therapies for the disease; or

(iii) no effective nonexperimental treatment for the disease exists;

• The Covered Person meets all inclusion criteria for the clinical trial and is not treated

“off-protocol”;

• The trial is approved by the Institutional Review Board of the institution administering the

treatment.

Routine patient services will include costs for services received during the course of a clinical

trial, which are the usual costs for medical care, such as Physician visits, Hospital stays, clinical

laboratory tests and x-rays that a Covered Person would receive whether or not he or she were

participating in a clinical trial, will not be considered Experimental or Investigational.

Routine patient services do not include, and reimbursement will not be provided for:

• The investigational service or supply itself;

• Services or supplies listed herein as Plan Exclusions;

• Services or supplies related to data collection for the clinical trial (i.e., protocol-induced

costs);

• Services or supplies which, in the absence of private health care coverage, are provided

by a clinical trial sponsor or other party (e.g. device, drug, item or service supplied by

manufacturer and not yet FDA approved) without charge to the trial participant.

(g)

(h)

Initial contact lenses or glasses required following cataract surgery.

Dental Injuries. Charges for Injury to the mouth and teeth will be Covered Charges under

Medical Benefits only if that care is for the following oral surgical procedures:

• Emergency repair and treatment made within six (6) months of an Injury to sound

natural teeth.

• Surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and

roof of the mouth.

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No charge will be covered under Medical Benefits for dental and oral surgical procedures

involving orthodontic care of the teeth, periodontal disease and preparing the mouth for the

fitting of or continued use of dentures.

Covered Charges will include those Medically Necessary charges made by a Hospital for

Inpatient Room and Board and supplies and services or charges made by a Free-Standing

Surgical facility or the outpatient department of a Hospital in connection with a surgery.

(i)

Durable medical or surgical equipment. Rental of durable medical or surgical equipment will

be a Covered Charge when deemed Medically Necessary. These items may be bought rather

than rented, with the cost not to exceed the fair market value of the equipment at the time of

purchase, but only if agreed to in advance by the Plan Administrator.

If the equipment is purchased, the purchase price will be prorated over a twelve (12) month

period, subject to benefits and eligibility.

Replacement equipment will be covered if the replacement equipment is required due to a

change in the Covered Person’s physical condition; or purchase of the new equipment will be

less expensive than the repair of existing equipment.

(j)

(k)

Erectile Dysfunction. Charges made for medical diagnostic services to determine the causes of

erectile dysfunction. Penile implants are covered for an established medical condition that

clearly is the cause of erectile dysfunction, such as postoperative prostatectomy and diabetes.

Penile implants are not covered as treatment of psychogenic erectile dysfunction.

Family Planning. Covered Charges made for Family Planning, including medical history,

physical exam, related laboratory tests, medical supervision in accordance with generally

accepted medical practices, and other medical services, information and counseling on

contraception, including implanted, injected contraceptives and contraceptive devices and

associated Physician’s charges.

Counseling for family planning will be payable per normal Plan provisions.

(l)

Genetic testing. Care, services and supplies in connection with genetic testing and genetic

counseling if:

i) the Covered Person has symptoms or signs of a genetically-linked inheritable disease; or

ii) it has been determined that a Covered Person is at risk for carrier status as supported by

existing peer-reviewed, evidence-based, scientific literature for the development of a

genetically-linked inheritable disease when the results will impact clinical outcome; or

iii) the therapeutic purpose is to identify specific genetic mutation that has been demonstrated

in the existing peer-reviewed, evidence-based, scientific literature to directly impact

treatment options.

Pre-implantation genetic testing, genetic diagnosis prior to embryo transfer, is covered when

either parent has an inherited disease or is a documented carrier of a genetically-linked

inheritable disease.

Genetic counseling is covered if a Covered Person is undergoing approved genetic testing, or if a

Covered Person has an inherited disease and is a potential candidate for genetic testing. Genetic

counseling is limited to 3 visits per Calendar Year for both pre- and post genetic testing.

El Paso County 21

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(m)

(n)

(o)

(p)

Home Infusion Therapy. The Plan will cover home infusion therapy services and supplies

when provided by an accredited home infusion therapy agency, which is not a licensed Home

Health Agency. These services must be Medically Necessary and are required for the

administration of a home infusion therapy regimen when ordered by and are part of a formal

written plan prescribed by a Physician. The benefit will include all Medically Necessary

services and supplies including the nursing services associated with patient and/or alternative

care giver training, visits to monitor intravenous therapy regimen, emergency care, Prescription

Drugs, administration of therapy and the collection, analysis and reporting of the results of

laboratory testing services required to monitor a response to therapy.

Jaw joint conditions. Medically Necessary services for care and treatment of jaw joint conditions,

including surgical and non-surgical treatment of Temporomandibular Joint syndrome (TMJ).

Laboratory studies. Covered Charges for diagnostic lab testing and services.

Mental Disorders and Substance Abuse. Covered Charges will be payable for care, supplies

and treatment of Mental Disorders and Substance Abuse.

• Bereavement counseling, when provided by a Mental Health provider, will be payable under

the Mental Disorders benefit under this Plan.

• Life Threatening Injuries. Medical treatment required as a result of an emergency, such as a

suicide attempt, will be considered a medical expense until the medical condition is

stabilized.

The following are specifically excluded from Mental Disorders and Substance Abuse services:

Developmental disorders, including but not limited to, developmental reading disorders,

developmental arithmetic disorders, developmental language or articulation disorders.

(q)

Morbid Obesity benefit. Charges for diagnostic testing, surgical and non-surgical procedures

for the treatment of Morbid Obesity, when deemed Medically Necessary for Covered Persons

ages 18 years and older or has reached full expected skeletal growth, including any associated

complications resulting from the direct or indirect surgery related to treatment under this benefit.

A pre-notification of services, by the Plan Participant is required prior to receiving either

inpatient or outpatient surgical procedures and will require the following documentation

including, but not limited to, a written treatment plan by the attending Physician and

documentation that all required medical criteria in advance of any surgical treatment has been

met.

Documentation that the Plan Participant has attempted weight loss in the past without successful

long term weight reduction will be required. The Plan Participant must have also participated

in the following criterion:

A Physician-supervised nutrition and exercise program (unless contraindicated). The Physiciansupervised

nutrition and exercise program must meet ALL of the following criteria and must

be supervised and monitored by a Physician working in cooperation

with a registered dietician and/or nutritionist:

o

o

o

The program must be twelve (12) months or longer in duration;

The program must occur within two (2) years prior to the surgery;

The program must be documented in the medical record by an attending Physician who

does not perform bariatric surgery.

El Paso County 22

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Covered Charges under this Morbid Obesity Benefit will also include Physician’s office visits,

related laboratory testing, surgical and non-surgical treatment.

The measurement of Body Mass Index (BMI) as defined under this Plan or a BMI of 35 or

greater with any co morbid conditions that are expected to improve, reverse or be limited by this

surgical treatment and which must be documented in a record or letter of medical necessity must

demonstrate the diagnosis of Morbid Obesity.

Dietary counseling will be covered under the separate Nutritional Evaluation benefit under this

Plan.

Weight loss medications prescribed by a Physician will not be payable under this Plan.

Programs such as Weight Watchers, Jenny Craig, and Optifast are acceptable alternatives if

done in conjunction with the supervision of a Physician or registered dietician and detailed

documentation of participation is available for review by the Claims Administrator. For

individuals with long-standing Morbid Obesity, participation in a program within the last five

(5) years is sufficient if reasonable attendance in the weight management program over an

extended period of time of at least six (6) months can be demonstrated. However, Physiciansupervised

programs consisting exclusively of pharmacological management are not sufficient to

meet this requirement.

Take-over provision: Morbid Obesity surgeries pre-approved prior to January 1, 2011 will be

covered under this Plan; however, documentation of the pre-approval must be provided to the

Claims Administrator prior to services being rendered. Note: Any change in the plan of care,

treatment, or modalities after the procedure had been initially pre-approved prior to

January 1, 2011, will require a new approval by the Claims Administrator before the

procedure(s) will be considered a Covered Charge under this Plan.

(r)

(s)

Nutritional Evaluation. Covered Charges for nutritional evaluation and counseling when diet is

a part of the medical management of a documented organic disease as well as for the treatment

of Morbid Obesity, and will be payable up to the limits as stated in the Schedule of Benefits.

Organ transplant benefits. Medically Necessary charges incurred for the care and treatment

due to an organ or tissue transplant, which are not considered Experimental or Investigational,

and which will also include the recipient’s medical, surgical, and Hospital services, including

the recipient’s inpatient immunosuppressive medications, and are subject to the following

criteria:

• The transplant must be performed to replace an organ or tissue.

• Organ procurement limits. Charges for obtaining donor organs or tissues (from a cadaver

or live donor) are Covered Charges under the Plan only when the recipient is a Covered

Person.

When the donor has medical coverage, his or her plan will pay first. The donor benefits under

this Plan will be reduced by those payable under the donor's plan. Donor charges include

those for:

(i)

(ii)

(iii)

(iv)

Evaluating the organ or tissue;

Removing the organ or tissue from a donor;

Transportation of the organ or tissue from within the United States or Canada to the

facility where the transplant is to be performed; and

The transportation, hospitalization and surgery of a live donor.

El Paso County 23

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Compatibility testing undertaken prior to procurement is covered if deemed Medically

Necessary. Costs related to the search for, and identification of a bone marrow or stem cell

donor for an allogeneic transplant are also covered.

Note: Expenses related to the purchase of any organ will not be covered.

As soon as reasonably possible, but in no event more than ten (10) days after a Covered

Person’s attending Physician has indicated that the Covered Person is a potential

candidate for a transplant, the Covered Person or his or her Physician must contact

CareLink at (866) 894-1505.

• In the event a Participating Provider transplant facility is utilized, benefits will be payable at

the Participating Provider benefit level.

• In the event a Participating Provider transplant facility is unavailable and the providing

transplant facility is a Center of Excellence facility, benefits will be payable at the

Participating Provider benefit level.

• In the event a non-Participating Provider transplant facility is utilized and the providing

transplant facility is not a Center of Excellence facility, there will not be any coverage

under this Plan.

A Center of Excellence is a licensed healthcare facility that has entered into a participation

agreement with a national transplant network to provide approved transplant services, at a

negotiated rate, to which the Plan has access. A Covered Person may contact CareLink to

determine whether or not a facility is considered a Center of Excellence.

Travel and Lodging Expenses

If the Covered Person resides 60 miles or more from the transplant facility, the Plan will pay for

the following services incurred during the transplant benefit period (subject to the maximum

benefit as specifically stated in the Schedule of Benefits):

A. Transportation expenses to and from the Participating Provider transplant facility or Center

of Excellence facility for the following individuals:

• The Covered Person; and

• One or both parents of the Covered Person (only if the Covered Person is a Dependent

minor child); or

• One adult to accompany the Covered Person.

Transportation expenses include commercial transportation (coach class only).

B. Reasonable lodging and meal expenses incurred for the Covered Person, and one or both

parents of the Covered Person (only if the Covered Person is a Dependent minor child), or

one adult companion who is accompanying the Covered Person, only while the Covered

Person is receiving transplant-related services at a Participating Provider transplant facility

or Center of Excellence facility.

The following are specifically excluded travel expenses:

o

o

Lodging will not include private residences.

Travel within 60 miles from a Covered Person’s residence.

o

Laundry bills, telephone bills, alcohol or tobacco products.

El Paso County 24

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Special Transplant Benefits

Under certain circumstances, there may be special transplant benefits available when the group

health plan and/or a Covered Person participates in a special transplant program and/or contracts

with a specific transplant network. Therefore, it is very important to contact CareLink at (866)

894-1505 as soon as reasonably possible so that the Plan can advise the Covered Person or his or

her Physician of the transplant benefits that may be available.

(t)

Orthognathic surgery. Orthognathic surgery to repair or correct a severe facial deformity or

disfigurement that orthodontics alone cannot correct, provided:

• The deformity or disfigurement is accompanied by a documented clinically significant

functional impairment, and there is a reasonable expectation that the procedure will result

in meaningful functional improvement; or

• The orthognathic surgery is Medically Necessary as a result of tumor, trauma, disease; or

• The orthognathic surgery is performed prior to age 19 years and is required as a result of

severe congenital facial deformity or congenital condition.

Repeat or subsequent orthognathic surgeries for the same condition are covered only when the

previous orthognathic surgery met the above requirements, and there is high probability of

significant additional improvement when determined by the Claims Administrator.

(u)

Orthotic appliances. The initial purchase, fitting and repair of orthotic appliances such as

braces, splints or other appliances which are required for support for an injured or deformed part

of the body as a result of a disabling congenital condition or an Injury or Sickness.

Corrective orthopedic shoes, arch supports or foot orthotics are not a Covered Charge under

this Plan.

(v)

(w)

(x)

Ostomy supplies. Medical ostomy supplies, when prescribed by a Physician, will be a Covered

Charge.

Prescription Drugs (as defined). Outpatient Prescription Drugs will not be a Covered Charge

under this Plan.

Routine Preventive Care. Covered Charges under Medical Benefits are payable for routine

Preventive Care as described in the Schedule of Benefits.

Charges for Routine Well Care. Routine well care is care by a Physician that is not for an

Injury or Sickness.

(y)

(z)

Prosthetic devices. The initial purchase, fitting and repair of fitted prosthetic devices which

replace missing body parts and are necessary to alleviate or correct Sickness, Injury or congenital

defect; including only artificial arms and legs, terminal devices such as hands or hooks.

Replacement of such prostheses is covered only if needed due to normal anatomical growth.

Reconstructive Surgery. Correction of abnormal congenital conditions and reconstructive

mammoplasties will be considered Covered Charges.

This mammoplasty coverage will include reimbursement for:

(i)

(ii)

reconstruction of the breast on which a mastectomy has been performed,

surgery and reconstruction of the other breast to produce a symmetrical appearance, and

El Paso County 25

Revised January 1, 2013

Standard Medical EPO


(iii)

coverage of prostheses and physical complications during all stages of mastectomy,

including lymphedemas,

in a manner determined in consultation with the attending Physician and the patient.

(a1)

Charges for Rehabilitation therapy. Services must be Medically Necessary to restore and

improve a bodily or cognitive function that was previously normal but was lost as a result of an

accidental Injury, Illness, or surgery.

Inpatient Care. Services must be furnished in a specialized rehabilitative unit of a Hospital and

billed by the Hospital or be furnished and billed by a rehabilitation facility approved by the Plan.

This benefit only covers care the Covered Person received within 24 months from the onset of

the Injury or Illness or from the date of the surgery that made rehabilitation necessary. The care

must also be part of a written plan of multidisciplinary treatment prescribed and periodically

reviewed by a physiatrist (a Physician specializing in rehabilitative medicine).

(a2)

Renal Dialysis Services. Renal dialysis visits, are paid at 200% of the Medicare equivalent

rate, up to the out-of-pocket limitation after the satisfaction of deductible, if any. For renal

dialysis treatments associated with an in-patient hospitalization, the Plan Administrator has the

discretionary authority to negotiate a contract rate or other discounting arrangement on the

entire inpatient claim.

Medicare Part B Reimbursement

If the Covered Person has End-Stage Renal Disease (“ESRD”), the Plan’s primary status

applies during the first thirty (30) months of dialysis, the first thirty (30) months of treatment in

connection with a transplant, or as otherwise directed by Centers of Medicare and Medicaid

Services (“CMS”) /Medicare coordination rules for ESRD. Thereafter, Medicare generally

becomes the primary payer of benefits.

The Medicare Secondary Payer statute requires the Plan to identify members in the Plan,

including eligible Dependents, who are eligible for Medicare, including those eligible based on

ESRD. To ensure the correct coordination of claims payments, members are required to

provide the Plan the basis for their eligibility to Medicare (age, ESRD, or disability) and the

effective date of Medicare Part A and Part B.

If the Covered Person becomes entitled, including dually entitled, to Medicare based on ESRD,

the Plan will reimburse the Covered Person up to a lifetime maximum amount of $5,000 for

Medicare Part B monthly premiums made during the period where the Plan has primary status.

Reimbursement for monies withheld by Medicare from Social Security, Railroad Retirement,

or Office of Personnel Management payments will be made at the end of each calendar quarter.

The Plan Administrator may require documentation of the payment of Part B premiums. For

additional information on how to submit a new request for reimbursement of Part B premiums,

please contact the Plan Administrator.

For more information on benefits available under the Medicare program, visit

www.medicare.gov or call toll-free 1 (800)-MEDICARE (1 (800) 633-4227). For more

information on Medicare Part B premiums, visit www.socialsecurity.gov, the local Social

Security office or call Social Security at 1 (800) 772-1213.

(a3)

Short-term Rehabilitative Therapy and Chiropractic Care. Charges made for Short-Term

Rehabilitative Therapy which is a part of a rehabilitation program, including physical, speech,

occupational, cardiac rehabilitation, and pulmonary rehabilitation therapy, when provided in the

most medically appropriate setting. Covered Charges will be payable up to the limits as stated in

the Schedule of Benefits.

Also included are Spinal Manipulation / Chiropractic services that are provided by a licensed

El Paso County 26

Revised January 1, 2013

Standard Medical EPO


M.D., D.O., or D.C. when provided in an outpatient setting. Services will include the

management of neuromusculoskeletal conditions through manipulation and ancillary

physiological treatment that is rendered to restore motion, reduce pain and improve function.

The following limitations will apply to Short-Term Rehabilitative Therapy and Chiropractic Care:

• Occupational therapy is provided only for purposes of training members to perform the

activities of daily living.

• Speech therapy is not covered when (a) used to improve speech skills that have not

fully developed; (b) considered custodial or educational; (c) intended to maintain

speech communication; or (d) not restorative in nature.

The following will not be a Covered Charge under this Plan:

Therapy or treatment intended primarily to improve or maintain general physical condition or

for the purpose of enhancing job, school, athletic, or recreational performance, including but not

limited to routine, long term, or maintenance care which is provided after the resolution of the

acute medical problem and when significant therapeutic improvement is not expected.

(a4)

(a5)

Sterilization procedures.

Stereotactic Radiosurgery (SRS). Covered Charges for Stereotactic Radiosurgery (SRS) and

Stereotactic Body Radiation Therapy (SBRT) including fractionated stereotactic radiotherapy and/or

stereotactic body radiation therapy when deemed Medically Necessary for ANY of the following

indications:

• Arteriovenous malformation of the brain or spine;

• Primary brain tumor (e.g. glioma, meningioma, pituitary tumor, hemangioblastoma, acoustic

neuroma (i.e., vestibular schwannoma), hypothalmic hamartoma);

• Metastatic tumor to the brain;

• Symptomatic primary or metastatic spinal tumor(e.g. neurological impairment, pain);

• Trigeminal neuralgia refractory to medical management;

• Nasopharyngeal cancer;

• Parkinsonian or essential tremor that is refractory to medical management;

• Uveal melanoma (melanoma of the uveal tract (iris, ciliary body and choroid));

• Any of the following neoplasms if unresectable or the Covered Person is a poor surgical

candidate or declines surgery:

‣ Liver malignancy

‣ Non small-cell lung cancer (NSCLC) or pulmonary metastasis

‣ Renal cell carcinoma (RCC) tumor

• Extracranial malignancy which is either in or adjacent to a previously irradiated volume, or

located near a critical structure, where the risk of toxicity precludes use of another local modality.

This Plan will not cover stereotactic radiosurgery including fractionated stereotactic radiotherapy and/or

stereotactic body radiation therapy for any other indication, including but not limited to the following, as

it is either considered Experimental / Investigational or unproven:

• Behavioral health disorders (e.g. obsessive-compulsive disorder)

• Breast Cancer

• Epilepsy

• Pancreatic Cancer

• Prostate Cancer

El Paso County 27

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(a6)

(a7)

Surgical dressings, splints, casts and other devices used in the reduction of fractures and

dislocations.

Well Newborn Routine Nursery/Physician Care.

Charges for Routine Nursery Care. Routine well newborn nursery care is care while the

newborn, who is neither injured nor ill, is Hospital-confined after birth and includes room,

board and other normal care, including circumcision, for which a Hospital makes a charge.

Coverage for a newborn who is either injured or ill at birth will be payable under the Plan of

the newborn child and will be payable per normal Plan provisions.

This coverage is only provided if the healthy newborn child is an eligible and enrolled

Dependent, as stated under the separate Enrollment Requirements For Newborn Children

section under this Plan, and a parent (1) is a Covered Person who was covered under the Plan at

the time of the birth, or (2) enrolls himself or herself (as well as the newborn child if required) in

accordance with the Special Enrollment provisions with coverage effective as of the date of

birth.

The benefit is limited to Usual and Reasonable Charges for nursery care for the newborn child

while Hospital confined as a result of the child's birth.

Charges for covered routine nursery care will be applied toward the Plan of the covered parent.

Group health plans generally may not, under Federal law, restrict benefits for any hospital

length of stay in connection with childbirth for the mother or newborn child to less than 48

hours following a vaginal delivery, or less than 96 hours following a cesarean section. However,

Federal law generally does not prohibit the mother's or newborn's attending provider, after

consulting with the mother, from discharging the mother or her newborn earlier than 48 hours

(or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require

that a provider obtain authorization from the plan or the issuer for prescribing a length of stay

not in excess of 48 hours (or 96 hours).

Charges for Routine Physician Care. The benefit is limited to the Usual and Reasonable

Charges made by a Physician, including circumcision, for the healthy newborn child while

Hospital confined as a result of the child's birth.

Charges for covered routine Physician care will be applied toward the Plan of the covered parent.

(a8)

Wigs. Charges associated with the initial purchase of a wig when deemed Medically Necessary

for Covered Persons suffering from either temporary or permanent hair loss as a result of an

Injury, Illness or medical treatment of another condition, such as chemotherapy, alopecia areata,

alopecia totalis, trichotillomania or any other clinical disease, must be prescribed by a Physician.

The Plan Administrator will require written confirmation and/or medical documentation from

the prescribing Physician confirming the Covered Person’s temporary or permanent hair loss

and that such purchase would improve the Covered Person’s mental well being.

NOTE: Naturally occurring hair loss is not considered a form of a disease and is not a Covered

Charge under this Plan.

(a9)

X-rays. Covered Charges for diagnostic x-ray services.

El Paso County 28

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THE WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 (WHCRA)

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) was signed into law on October 21, 1998.

In the case of an Employee or Dependent who receives benefits under the plan in connection with a mastectomy

and who elects breast reconstruction (in a manner determined in consultation with the attending physician and the

patient), coverage will be provided for:

• Reconstruction of the breast on which the mastectomy was performed.

• Surgery and reconstruction of the other breast to produce a symmetrical appearance.

• Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.

Benefits will be subject to the same cost-sharing (deductible, co-payment, co-insurance) provisions as apply

to the mastectomy.

El Paso County 29

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COST MANAGEMENT SERVICES

COORDINATED CARE

Coordinated Care is a program designed to assist Covered Persons in understanding and becoming involved with their

diagnosis and medical plan of care, and advocates patient involvement in choosing a medical plan of care.

Coordinated Care begins with the pre-notification process.

Pre-notification of certain services is strongly recommended, but not required by the Plan. Pre-notification provides

information regarding coverage before the Covered Person receives treatment, services and/or supplies. A benefit

determination on a Claim will be made only after the Claim has been submitted. A pre-notification of services by

CareLink is not a determination by the Plan that a Claim will be paid. All Claims are subject to the terms and

conditions, limitations and exclusions of the Plan at the time charges are incurred. A pre-notification is not required

as a condition precedent to paying benefits, and cannot be appealed.

Examples of when the Physician and Covered Person should contact CareLink prior to treatment include:

• Inpatient admissions to a Hospital

• Inpatient admissions to free-standing chemical dependency, mental health, and rehabilitation facilities

• Cancer treatment programs, administered on an inpatient or outpatient basis

• Inpatient or outpatient surgeries relating to, but not limited to, hysterectomies, back surgery, or bariatric

surgery (if applicable under this Plan).

All Claims are subject to the terms and conditions, limitations and exclusions of the Plan at the time charges are

incurred.

The Physician or Covered Person should notify CareLink at least seven (7) days before services are scheduled to be

rendered with the following information:

• The name of the patient and relationship to the covered Employee

• The name, Employee identification number and address of the Covered Person

• The name of the Employer

• The name and telephone number of the attending Physician

• The name of the Hospital, proposed date of admission, and proposed length of stay

• The diagnosis and/or type of surgery

• The plan of care, treatment protocol and/or informed consent, if applicable

If there is an emergency admission to the Hospital, the Covered Person, Covered Person’s family member, Hospital

or attending Physician should notify CareLink within two (2) business days after the admission.

Hospital Observation Room stays in excess of 23 hours are considered an admission for purposes of this program,

therefore CareLink should be notified.

El Paso County 30

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Standard Medical EPO


Contact the Coordinated Care administrator at:

CareLink (406) 245-3575 or (866) 894-1505

Monday through Thursday, 7:00 a.m. to 7:00 p.m. (Mountain Time)

Friday, 7:00 a.m. to 6:00 p.m. (Mountain Time)

A CareLink nurse will contact the Covered Person to provide health education, pre-surgical counseling, inpatient care

coordination, facilitation of discharge plan and post-discharge follow-up.

PRE-NOTIFICATION DETERMINATION AND REVIEW PROCESS

The Claims Administrator, on the Plan’s behalf, will review the submitted information and make a determination on a

pre-notification request within fifteen (15) days of receipt of the pre-notification request and all supporting

documentation. If additional records are necessary to process the pre-notification request, the Claims Administrator

will notify the Covered Person or the Physician. The time for making a determination on the request will be deferred

from the date that the additional information is requested until the date that the information is received.

The Physician and Covered Person will be provided notice of the Plan’s determination. In the case of an adverse prenotification

determination, written notice will provide the reason for the adverse pre-notification determination. If the

pre-authorization request is denied, written notice will provide the reason for the adverse pre-notification

determination.

The Plan offers a one-level review procedure for adverse pre-notification determinations. The request for

reconsideration must be submitted in writing within thirty (30) days of the receipt of the adverse pre-notification

determination and include a statement as to why the Covered Person disagrees with the adverse pre-notification

determination. The Covered Person may include any additional documentation, medical records, and/or letters from

the Covered Person’s treating Physician(s). The request for reconsideration should be addressed to:

Plan Administrator

c/o Employee Benefit Management Services, Inc.

Attn: Claims Appeals

P.O. Box 21367

Billings, Montana 59104

The Plan Administrator or its designee will perform the reconsideration review. The Plan Administrator or its

designee will review the information initially received and any additional

information provided by the Covered Person, and determine if the pre-notification determination was appropriate. If

the adverse pre-notification determination was based upon the medical necessity, the Experimental/ Investigational

nature of the treatment, service or supply or an equivalent exclusion, the Plan may consult with a health care

professional who has the appropriate training and experience in the applicable field of medicine. Written or electronic

notice of the determination upon reconsideration will be provided within thirty (30) days of the receipt of the request

for reconsideration.

CASE MANAGEMENT

If a Covered Person has an ongoing medical condition or catastrophic Illness, a Case Manager may be assigned to

monitor this Covered Person, and to work with the attending Physician and Covered Person to design a treatment plan

and coordinate appropriate Medically Necessary care. The Case Manager will consult with the Covered Person, the

family, and the attending Physician in order to assist in coordinating the plan of care approved by the Covered

Person’s attending Physician and the Covered Person.

This plan of care may include some or all of the following:

• Individualized support to the patient;

• Contacting the family to offer assistance for coordination of medical care needs;

• Monitoring response to treatment;

El Paso County 31

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Standard Medical EPO


• Evaluating outcomes; and

• Assisting in obtaining any necessary equipment and services.

Case Management is not a requirement of the Plan. There are no reductions of benefits or penalties if the

Covered Person and family choose not to participate.

Each treatment plan is individualized to a specific Covered Person and is not appropriate or recommended for

any other patient, even one with the same diagnosis. All treatment and care decisions will be the sole

determination of the Covered Person and the attending Physician.

TELEPHONE CONSULTATION

Nurses are available by a toll-free line during CareLink normal working hours to answer a Covered Person’s healthrelated

questions. Assistance ranges from providing a better understanding of specific medical procedures, to plain

English translations of medical terminology and help in locating community support services.

CareLink PRIORITY MATERNITY CARE

Priority Maternity Care is an educational and empowerment program for eligible female Employees, Spouses and

Dependent daughters.

This program provides a means to positively affect a Pregnancy and the health of the baby.

A CareLink nurse will set up a confidential, personal telephone interview to identify medical history and lifestyles that

could have an impact on the outcome of the Pregnancy.

A CareLink nurse is available to assist and coordinate high risk aspects of maternity care. This includes providing

information such as access to educational programs and community resources designed to meet the needs identified by

the patient or Physician.

Certification Requirements: The Covered Person needs to notify CareLink by the end of the second trimester of her

Pregnancy.

El Paso County 32

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DEFINED TERMS

The following terms have special meanings and when used in this Plan will be capitalized.

Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform the

duties of his or her job with the Employer on a full-time basis.

Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a staff

of Physicians, has continuous Physician and nursing care by registered nurses (R.N.s) and does not provide for

overnight stays.

Birthing Center means any freestanding health facility, place, professional office or institution which is not a

Hospital or in a Hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated

in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located.

The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide

care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse-midwife;

and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop

complications or require pre- or post-delivery confinement.

Calendar Year means January 1st through December 31st of the same year.

COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Covered Charge(s) means those Medically Necessary services or supplies that are covered under this Plan.

Covered Person is an Employee, a pre-Medicare eligible Retiree or a Dependent who is covered under this Plan.

Creditable Coverage includes most health coverage, such as coverage under a group health plan (including COBRA

continuation coverage), HMO membership, an individual health insurance policy, Medicaid, Medicare or public

health plans.

Creditable Coverage does not include coverage consisting solely of dental or vision benefits.

Creditable Coverage does not include coverage that was in place before a significant break of coverage of 63 days or

more. With respect to the Trade Act of 2002, when determining whether a significant break in coverage has occurred,

the period between the trade related coverage loss and the start of the special second COBRA election period under

the Trade Act, does not count.

Credited Service as defined under the El Paso County Retirement Plan Plan Document (as amended).

Custodial Care is care (including Room and Board needed to provide that care) that is given principally for personal

hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed

by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed;

assistance in bathing, dressing, feeding; or supervision over medication which could normally be self-administered.

Durable Medical Equipment means equipment which (a) can withstand repeated use, (b) is primarily and

customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of an Illness or

Injury and (d) is appropriate for use in the home.

Employee means a person who is an Active, regular Employee of the Employer, regularly scheduled to work for the

Employer in an Employee/Employer relationship.

The term “Employee” does not include Employees who are part-time, temporary, or who normally work less than 40

hours per week for the Employer.

Employer is El Paso County.

El Paso County 33

Revised January 1, 2013

Standard Medical EPO


Enrollment Date is the first day of coverage or, if there is a Waiting Period, the first day of the Waiting Period.

Experimental and/or Investigational means services, supplies, care and/or treatment which does not constitute

accepted medical practice properly within the range of appropriate medical practice under the standards of the case

and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical and dental

community or government oversight agencies at the time services were rendered.

The Plan Administrator must make an independent evaluation of the experimental/non-experimental standings of

specific technologies. The Plan Administrator may request specific documentation, including but not limited to the

covered person’s plan of care, treatment protocol and/or informed consent. The Plan Administrator shall be guided

by a reasonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a

detailed factual background investigation of the claim and the proposed treatment. The decision of the Plan

Administrator will be final and binding on the Plan. The Plan Administrator will be guided by the following

principles:

(1) If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug

Administration and approval for marketing has not been given at the time the drug or device is furnished; or

(2) If the drug, device, medical treatment or procedure, or the patient informed consent document utilized with the

drug, device, treatment or procedure, was reviewed and approved by the treating facility's Institutional Review

Board or other body serving a similar function, or if federal law requires such review or approval; or

(3) Except as otherwise stated below for cancer treatment, if Reliable Evidence shows that the drug, device,

medical treatment or procedure is the subject of on-going phase I or phase II clinical trials, is the research

experimental, study or investigational arm of an on-going phase III clinical trial, or is otherwise under study

to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with

a standard means of treatment or diagnosis; or

(4) If Reliable Evidence shows that the drug, device, medical treatment or procedure is under study, prior to or

in the absence of any clinical trial, to determine its maximum tolerated dose, its toxicity, its safety, its

efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or

(5) If Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device, medical

treatment or procedure is that further studies or clinical trials are necessary to determine its maximum

tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of

treatment or diagnosis.

Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature;

the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying

substantially the same drug, service, medical treatment or procedure; or the written informed consent used by the

treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure.

For purposes of this Plan, routine patient services for cancer clinical trials are a Covered Charge as specifically

stated as a benefit under this Plan.

Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved

by the Food and Drug Administration for general use.

Family Unit is the covered Employee and the family members who are covered as Dependents under the Plan.

Genetic Information means information about the genetic tests of an individual or his family members, and

information about the manifestations of disease or disorder in family members of the individual. A "genetic test"

means an analysis of human DNA, RNA, chromosomes, proteins or metabolites, which detects genotypes, mutations

or chromosomal changes. It does not mean an analysis of proteins or metabolites that is directly related to a

manifested disease, disorder or pathological condition that could reasonably be detected by a health care professional

with appropriate training and expertise in the field of medicine involved. Genetic information does not include

information about the age or gender of an individual.

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Revised January 1, 2013

Standard Medical EPO


Home Health Care Agency is an organization that meets all of these tests: its main function is to provide Home

Health Care Services and Supplies; it is federally certified as a Home Health Care Agency; and it is licensed by the

state in which it is located, if licensing is required.

Home Health Care Plan must meet these tests: it must be a formal written plan made by the patient's attending

Physician which is reviewed at least every 30 days; it must state the diagnosis; it must certify that the Home Health

Care is in place of Hospital confinement; and it must specify the type and extent of Home Health Care required for

the treatment of the patient.

Home Health Care Services and Supplies include: part-time or intermittent nursing care by or under the supervision

of a registered nurse (R.N.); part-time or intermittent home health aide services provided through a Home Health Care

Agency (this does not include general housekeeping services); physical, occupational and speech therapy; medical

supplies; and laboratory services by or on behalf of the Hospital.

Hospice Agency is an organization where its main function is to provide Hospice Care Services and Supplies and it is

licensed by the state in which it is located, if licensing is required.

Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Agency and

supervised by a Physician.

Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice Care Plan

and include inpatient care in a Hospice Unit or other licensed facility, home care, and family counseling during the

bereavement period.

Hospice Unit is a facility or separate Hospital Unit, that provides treatment under a Hospice Care Plan and admits at

least two unrelated persons who are expected to die within six months.

Hospital is an institution that is engaged primarily in providing medical care and treatment of sick and injured

persons on an inpatient basis at the patient's expense and that fully meets these tests: it is approved by Medicare as a

Hospital; it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and

treatment of sick and injured persons by or under the supervision of a staff of Physicians; it continuously provides on

the premises 24-hour nursing services by or under the supervision of registered nurses (R.N.s); and it is operated

continuously with organized facilities for operative surgery on the premises.

The definition of "Hospital" shall be expanded to include the following:

• A facility operating legally as a psychiatric Hospital or residential treatment facility for mental health and

licensed as such by the state in which the facility operates.

• A facility operating primarily for the treatment of Substance Abuse if it has received accreditation from

CARF (Commission of Accreditation of Rehabilitation Facilities) or JCAHO (Joint Commission of

Accreditation of Hospital Organizations) or if it meets these tests: maintains permanent and full-time

facilities for bed care and full-time confinement of at least 15 resident patients; has a Physician in regular

attendance; continuously provides 24-hour nursing service by a registered nurse (R.N.); has a full-time

psychiatrist or psychologist on the staff; and is primarily engaged in providing diagnostic and therapeutic

services and facilities for treatment of Substance Abuse.

Illness means a bodily disorder, disease, physical sickness or Mental Disorder. Illness includes Pregnancy, childbirth,

miscarriage or complications of Pregnancy.

Injury means an accidental physical Injury to the body caused by unexpected external means.

Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a Hospital

solely for the care and treatment of patients who are critically ill. This also includes what is referred to as a "coronary

care unit" or an "acute care unit." It has: facilities for special nursing care not available in regular rooms and wards of

the Hospital; special life saving equipment which is immediately available at all times; at least two beds for the

accommodation of the critically ill; and at least one registered nurse (R.N.) in continuous and constant attendance 24

hours a day.

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Revised January 1, 2013

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Late Enrollee means a Plan Participant who enrolls under the Plan other than during the first 31-day period in which

the individual is eligible to enroll under the Plan or during a Special Enrollment Period.

Medical Care Facility means a Hospital, a facility that treats one or more specific ailments or any type of Skilled

Nursing Facility.

Medical Emergency means a sudden onset of a condition with acute symptoms requiring immediate medical care

and includes such conditions as heart attacks, cardiovascular accidents, poisonings, loss of consciousness or

respiration, convulsions or other such acute medical conditions.

Medical Non-Emergency Care means care which can safely and adequately be provided other than in a Hospital.

Medically Necessary care and treatment is recommended or approved by a Physician; is consistent with the patient's

condition or accepted standards of good medical practice; is medically proven to be effective treatment of the

condition; is not performed mainly for the convenience of the patient or provider of medical services; and is the most

appropriate level of services which can be safely provided to the patient.

All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean

that it is Medically Necessary.

The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary.

Medicare is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security Act,

as amended.

Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is classified as a

Mental Disorder in the current edition of International Classification of Diseases, published by the U.S. Department

of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental

Disorders, published by the American Psychiatric Association.

Morbid Obesity is a serious disease associated with a high incidence of medical complications and a significantly

shortened life span. The current clinical standard measure for Morbid Obesity is a Body Mass Index (BMI) of 40+.

The BMI is a factor produced by dividing a person’s weight (in kilograms) by his or her height squared (in meters).

No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining

fault in connection with automobile accidents.

Outpatient Care and/or Services is treatment including services, supplies and medicines provided and used at a

Hospital under the direction of a Physician to a person not admitted as a registered bed patient; or services rendered in

a Physician's office, laboratory or X-ray facility, an Ambulatory Surgical Center, or the patient's home.

Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of

Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed

Professional Physical Therapist, Master of Social Work (M.S.W.), Midwife, Occupational Therapist, Physiotherapist,

Psychiatrist, Psychologist (Ph.D.), Speech Language Pathologist and any other practitioner of the healing arts who is

licensed and regulated by a state or federal agency and is acting within the scope of his or her license.

Plan means El Paso County, which is a benefits plan for certain Employees of El Paso County and is described in this

document.

Plan Participant is any Employee, pre-Medicare eligible Retiree or Dependent who is covered under this Plan.

Plan Year is the 12-month period beginning on either the effective date of the Plan or on the day following the end of

the first Plan Year which is a short Plan Year.

Pregnancy is childbirth and conditions associated with Pregnancy, including complications.

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Revised January 1, 2013

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Prescription Drug means any of the following: a Food and Drug Administration-approved drug or medicine which,

under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription";

injectable insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed

Physician. Such drug must be Medically Necessary in the treatment of a Sickness or Injury.

Sickness is a person's Illness, disease or Pregnancy (including complications).

Skilled Nursing Facility is a facility that fully meets all of these tests:

(1) It is licensed to provide professional nursing services on an inpatient basis to persons convalescing from

Injury or Sickness. The service must be rendered by a registered nurse (R.N.) or by a licensed practical

nurse (L.P.N.) under the direction of a registered nurse. Services to help restore patients to self-care in

essential daily living activities must be provided.

(2) Its services are provided for compensation and under the full-time supervision of a Physician.

(3) It provides 24 hour per day nursing services by licensed nurses, under the direction of a full-time

registered nurse.

(4) It maintains a complete medical record on each patient.

(5) It has an effective utilization review plan.

(6) It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mentally disabled,

Custodial or educational care or care of Mental Disorders.

(7) It is approved and licensed by Medicare.

This term also applies to charges incurred in a facility referring to itself as an extended care facility, convalescent

nursing home, rehabilitation hospital, long-term acute care facility or any other similar nomenclature.

Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or other treatment in connection

with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human

body. Such treatment is done by a Physician to remove nerve interference resulting from, or related to, distortion,

misalignment or subluxation of, or in, the vertebral column.

Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs.

This does not include dependence on tobacco and ordinary caffeine-containing drinks.

Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders including conditions of

structures linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the

temporomandibular joint.

Total Disability (Totally Disabled) means: In the case of a Dependent child, the complete inability as a result of

Injury or Sickness to perform the normal activities of a person of like age and sex in good health.

Usual and Reasonable Charge is a charge which is not higher than the usual charge made by the provider of the care

or supply and does not exceed the usual charge made by most providers of like service in the same area. This test will

consider the nature and severity of the condition being treated. It will also consider medical complications or unusual

circumstances that require more time, skill or experience.

The Plan will reimburse the actual charge billed if it is less than the Usual and Reasonable Charge. The Plan Administrator

has the discretionary authority to decide whether a charge is Usual and Reasonable.

El Paso County 37

Revised January 1, 2013

Standard Medical EPO


PLAN EXCLUSIONS

For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:

(1) Abortion. Services, supplies, care or treatment in connection with an abortion unless the life of the

mother is endangered by the continued Pregnancy or the Pregnancy is the result of rape or incest.

(2) Acupuncture. Care, treatment, services and supplies in connection with acupuncture or acupressure.

(3) Biologicals. The cost of biologicals that are immunizations or medications for the purpose of travel, or to

protect against occupational hazards and risks.

(4) Clinical indication. Regardless of clinical indication charges for blepharoplasty; rhinoplasty; dance

therapy; movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave

lithotripsy (ESWL) for musculoskeletal and orthopedic conditions.

(5) Coding Guidelines. Charges for inappropriate coding in accordance to the industry standard guidelines

in effect at the time services were received.

(6) Complications of non-covered treatments. Care, services or treatment required as a result of

complications from a treatment not covered under the Plan are not covered.

(7) Cosmetics. Cosmetics, dietary supplements and health and beauty aids.

(8) Cosmetic surgery. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve

or alter appearance or self-esteem to treat psychological symptomatology or psychosocial complaints

related to one’s appearance.

(9) Counseling. Care and treatment for marital, pre-marital counseling, educational, vocational, religious, or

occupational counseling.

(10) Court ordered treatment or therapy. Court ordered treatment or therapy or any treatment or therapy

ordered as a condition of parole, probation, custody or visitation evaluations unless deemed Medically

Necessary and otherwise covered under the Plan.

(11) Custodial care. Services or supplies provided mainly as a rest cure, maintenance or Custodial Care,

except as specifically stated as a benefit under this Plan.

(12) Dental care. Care, treatment, services and supplies for treatment of the teeth or dental care, except as

specifically stated as a benefit under this Plan for dental injuries.

(13) Dental implants. Dental implants for any condition.

(14) Devices. Aids and devices that assist with nonverbal communication, including but not limited to

communication boards, prerecorded speech devices, computers, Personal Digital Assistants (PDAs),

Braille typewriters, visual alert systems for the deaf and memory books.

(15) Educational or vocational testing. Services for educational or vocational testing or training, except as

specifically stated as a benefit under this Plan.

(16) Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in excess

of the Usual and Reasonable Charge.

(17) Exercise programs. Exercise programs, health clubs, or weight loss programs for treatment of any

condition, except for Physician-supervised cardiac rehabilitation, occupational or physical therapy

covered by this Plan.

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Revised January 1, 2013

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(18) Experimental or not Medically Necessary. Care and treatment that is either Experimental /

Investigational or not Medically Necessary.

(19) Eye care. Radial keratotomy or other eye surgery to correct refractive disorders. Also, routine eye

examinations, including refractions, lenses for the eyes and exams for their fitting. This exclusion does

not apply to aphakic patients and soft lenses or sclera shells intended for use as corneal bandages.

(20) Foot care. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions

(except open cutting operations), and treatment of corns, calluses or toenails (unless needed in treatment

of a metabolic or peripheral-vascular disease) or except as otherwise deemed Medically Necessary.

(21) Foreign travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of obtaining

medical services.

(22) Government coverage. Care, treatment or supplies furnished by a program or agency funded by any

government. This does not apply to Medicaid or when otherwise prohibited by law.

(23) Hair loss. Care and treatment for hair loss including hair transplants or any drug that promises hair

growth, whether or not prescribed by a Physician. Wigs, when deemed Medically Necessary, will only

be payable as stated as a benefit under this Plan.

(24) Hearing aids and exams. Charges for services or supplies in connection with hearing aids or exams for

their fitting.

(25) Homeopathy. Care, treatment, services and supplies in connection with homeopathic medicine.

(26) Hospital employees. Professional services billed by a Physician or nurse who is an employee of a

Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service.

(27) Illegal acts. Charges for services received as a result of an Illness or Injury occurring directly, or

indirectly as a result of a serious criminal act, or a riot or public disturbance, or regardless of causation, if

such Illness or Injury occurs in connection with, or while engaged in, or attempting to engage in, a

serious criminal act, or a riot or public disturbance. For the purposes of this exclusion, the term "serious

criminal act" shall mean any act or series of acts by the Plan Participant, or by the Plan Participant in

concert with another or others, for which, if prosecuted as a criminal offense, a sentence to a term of

imprisonment in excess of one year could be imposed. For this exclusion to apply, it is not necessary that

criminal charges be filed, or if filed, that a conviction result, or that a sentence of imprisonment for a

term in excess of one year be imposed. This exclusion does not apply if the Injury resulted from an act of

domestic violence or a medical (including both physical and mental health) condition.

Charges for services, supplies, care or treatment to a Plan Participant for an Injury or Illness which

occurred as a result of that Plan Participant operating a motor vehicle while under the influence of

alcohol or drugs or a combination thereof or operating a motor vehicle with a blood or breath alcohol

content (BAC) above the legal limit. The arresting officer’s determination of inebriation will be

sufficient for this exclusion. It is not necessary for this exclusion to apply that criminal charges be filed,

or if filed, that a conviction result. Expenses will be covered for injured Plan Participants other than the

person operating the vehicle while under the influence or a BAC above the legal limit, and expenses may

be covered for chemical dependency treatment as specified in this Plan. This exclusion does not apply if

the Injury resulted from an act of domestic violence or a medical (including both physical and mental

health) condition.

(28) Impotence. Charges for treatment of erectile or sexual dysfunction, except as specifically stated as a

benefit under this Plan.

(29) Infertility. Care, supplies, services and treatment for infertility, artificial insemination, or in vitro

fertilization. Treatment for an underlying medical condition will be covered only up to the point an

infertility condition is diagnosed and will be payable per normal Plan provisions.

El Paso County 39

Revised January 1, 2013

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(30) Mailing or Sales Tax. Charges for mailing, shipping, handling, conveyance and sales tax.

(31) Massage therapy. Care, services, supplies and treatment in connection with massage therapy.

(32) Medical supplies. Consumable medical supplies other than ostomy supplies and urinary catheters.

Excluded supplies include, but are not limited to, bandages and other disposable medical supplies, skin

preparations, diabetic supplies (including test strips, alcohol swabs, syringes, lancets) except as deemed

Medically Necessary in connection with Home Health Services or the Reconstructive Surgery benefits

under this Plan.

(33) Naturopath. Care, treatment, services and supplies in connection with naturopathic medicine.

(34) No charge. Care and treatment for which there would not have been a charge if no coverage had been in

force.

(35) Non-emergency Hospital admissions. Care and treatment billed by a Hospital for non-Medical

Emergency admissions on a Friday or a Saturday. This does not apply if surgery is performed within 24

hours of admission.

(36) Non-Participating Provider. Medical treatment when payment is denied because treatment was

received from a Non-Participating Provider, except as specifically stated as a benefit under this Plan.

(37) No obligation to pay. Charges incurred for which the Plan has no legal obligation to pay.

(38) No Physician recommendation. Care, treatment, services or supplies not recommended and approved

by a Physician; or treatment, services or supplies when the Covered Person is not under the regular care

of a Physician. Regular care means ongoing medical supervision or treatment which is appropriate care

for the Injury or Sickness.

(39) Not specified as covered. Non-traditional medical services, treatments and supplies which are not

specified as covered under this Plan.

(40) Nutritional supplements and formulae except for infant formula needed for the treatment of inborn

errors of metabolism.

(41) Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a

part of the treatment plan for another Sickness, except as specifically stated as a benefit under this Plan.

(42) Occupational Injury. Care and treatment of an Injury or Sickness that is occupational – that is, arises

from work for wage or profit including self-employment. This exclusion applies even though the Plan

Participant:

(a)

(b)

(c)

Has waived his/her rights to Workers’ Compensation benefits;

Was eligible for Workers’ Compensation benefits and failed to properly file a claim for such

benefits; or

The Plan Participant is permitted to elect not to be covered under Workers’ Compensation and

has affirmatively made that election.

(43) Personal comfort items. Personal comfort items, patient convenience items, or other equipment, such

as, but not limited to, air conditioners, air-purification units, humidifiers, electric heating units,

orthopedic mattresses, blood pressure instruments, scales, elastic bandages or stockings, nonprescription

drugs and medicines, and first-aid supplies and nonhospital adjustable beds.

El Paso County 40

Revised January 1, 2013

Standard Medical EPO


(44) Plan design excludes. Charges excluded by the Plan design as mentioned in this document.

(45) Prescription Drugs. All noninjectable Prescription Drugs, injectable Prescription Drugs that do not

require a Physician’s supervision (i.e., self-administered drugs), non-Prescription Drugs, and

Prescription Drugs considered Experimental / Investigational, except as specifically stated as a benefit

under this Plan.

(46) Psychological testing. Charges for psychological testing requested by or for a school system.

(47) Relative giving services. Professional services performed by a person who ordinarily resides in the

Covered Person's home or is related to the Covered Person as a Spouse, parent, child, brother or sister,

whether the relationship is by blood or exists in law.

(48) Replacement braces. Replacement of braces of the leg, arm, back, neck, or artificial arms or legs, unless

there is sufficient change in the Covered Person's physical condition to make the original device no

longer functional.

(49) Reports. Charges for reports, evaluations, physical examinations, or hospitalization not required for

health reasons including, but not limited to, employment, insurance or government licenses, and courtordered,

forensic or custodial evaluations.

(50) Routine care. Charges for routine or periodic examinations, screening examinations, evaluation

procedures, preventive medical care, or treatment or services not directly related to the diagnosis or

treatment of a specific Injury, Sickness or Pregnancy-related condition which is known or reasonably

suspected, unless such care is specifically covered in the Schedule of Benefits.

(51) Services before or after coverage. Care, treatment or supplies for which a charge was incurred before a

person was covered under this Plan or after coverage ceased under this Plan.

(52) Sex changes. Care, services or treatment for non-congenital transsexualism, gender dysphoria or sexual

reassignment or change. This exclusion includes medications, implants, hormone therapy, surgery,

medical or psychiatric treatment.

(53) Sleep disorders. Care and treatment for sleep disorders unless deemed Medically Necessary.

(54) Smoking cessation. Care and treatment for smoking cessation programs, including smoking deterrent

products.

(55) Surgical sterilization reversal. Care and treatment for reversal of surgical sterilization.

(56) Telephone. Telephone, e-mail, Internet consultations and telemedicine.

(57) Travel or accommodations. Charges for travel or accommodations, whether or not recommended by a

Physician, except as specifically stated as a benefit under this Plan.

(58) War. Any loss that is due to a declared or undeclared act of war.

El Paso County 41

Revised January 1, 2013

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HOW TO SUBMIT A CLAIM

When services are received from a health care provider, a Plan Participant should show his or her EBMS/El Paso

County Government Identification card to the provider. Preferred Providers may submit claims on a Plan

Participant’s behalf.

If it is necessary for a Plan Participant to submit a claim, he or she should request an itemized bill which includes

procedure (CPT) and diagnostic (ICD-9) codes from his or her health care provider.

To assist the Claims Administrator in processing the claim, the following information must be provided when

submitting the claim for processing:

• A copy of the itemized bill

• Group name and number (El Paso County Government, Group #0000286)

• Provider Billing Identification Number

• Employee's name and Identification Number

• Name of patient

• Name, address, telephone number of the provider of care

• Date of service(s)

• Place of service

• Amount billed

Note: A Plan Participant can obtain a claim form from the Plan Administrator or the Claims Administrator. Claim

forms are also available at http://www.ebms.com.

WHERE TO SUBMIT CLAIMS

Employee Benefit Management Services, Inc., is the Claims Administrator.

Cofinity Network is the primary Participating Provider Organization under this Plan. Claims for expenses should be

submitted to this Participating Provider for Network repricing (as applicable) at the address below:

Cofinity Network

P.O. Box 2720

Farmington Hills, MI 48333

(800) 831-1166

www.cofinity.net

WHEN CLAIMS SHOULD BE FILED

Claims must be filed with the Claims Administrator within 365 days of the date charges for the service were incurred.

Benefits are based on the Plan's provisions at the time the charges were incurred. Claims filed later than that date will

be declined.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of

the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan

Participant seek a second medical opinion.

CLAIMS REVIEW PROCEDURE

A Claim means a request for a Plan benefit, made by a Plan Participant or by an authorized representative of a Plan

Participant that complies with the Plan's reasonable procedures for filing benefit Claims. A Claim for benefits is not a

Claim that has been previously submitted, denied, appealed, and re-denied upon appeal.

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A “Claim” is a Post-Service Claim under the terms of the Plan. A Post-Service Claim means a Claim for covered

medical services that have already been received by the Plan Participant.

All questions regarding Claims should be directed to the Claims Administrator. All claims will be considered for

payment according to the Plan’s terms and conditions, limitations and exclusions, and industry standard guidelines in

effect at the time charges were incurred. The Plan may, when appropriate or when required by law, consult with

relevant health care professionals and access professional industry resources in making decisions about claims

involving specialized medical knowledge or judgment. The Plan Administrator shall have full responsibility to

adjudicate all claims and to provide a full and fair review of the initial claim determination in accordance with the

following Claims review procedure.

A Claim will not be deemed submitted until it is received by the Claims Administrator.

For the purposes of this section, Claimant means the Plan Participant or the Plan Participant’s authorized

representative. A Claimant may appoint an authorized representative to act upon his or her behalf with respect to the

Claim. Contact the Claims Administrator for information on the Plan’s procedures for authorized representatives. A

Claimant does not include a healthcare provider simply by virtue of an assignment of benefits.

An Adverse Benefit Determination shall mean a denial, reduction, or termination of, or a failure to provide or make

payment (in whole or in part) for, a benefit. An inquiry regarding eligibility or benefits without a Claim for benefits is

not a Claim and, therefore, cannot be appealed.

Initial Benefit Determination

The Initial Benefit Determination on a Post-Service Claim will be made within 30 days of the Claim Administrator’s

receipt of the Claim. If the Claims Administrator requires an extension due to circumstances beyond the Plan’s

control, the Claims Administrator will notify the Claimant of the reason for the delay within the initial 30-day period.

A benefit determination on the Claim will be made within 15 days of the date the notice of the delay was provided to

the Claimant. If additional information is necessary to process the Claim, the Claims Administrator will request the

additional information from the Claimant within the initial 30-day period. The Claimant must submit the requested

information within 45 days of receipt of the request from the Claims Administrator. Failure to submit the requested

information within the 45-day period may result in a denial of the Claim or a reduction in benefits. A benefit

determination on the Claim will be made within 15 days of the Plan’s receipt of the additional information.

Notice of Determination

The Plan shall provide written or electronic notice of the determination on a Claim in a manner meant to be

understood by the Claimant. If a Claim is denied in whole or in part, notice will include the following:

(1) Specific reason(s) for the denial.

(2) Reference to the specific Plan provisions on which the denial was based.

(3) Description of any additional information necessary for the Claimant to perfect the Claim and an explanation

of why such information is necessary.

(4) Description of the Plan's Claims review procedures and the time limits applicable to such procedures.

(5) Statement that the Claimant is entitled to receive, upon request and free of charge, reasonable access to, and

copies of, all documents, records, and other information relevant to the Claim.

If applicable:

(6) Any internal rule, guideline, protocol, or other similar criterion that was relied upon in making the

determination on the Claim (or a statement that such a rule, guideline, protocol, or criterion was relied upon

in making the Adverse Benefit Determination and that a copy will be provided free of charge to the Claimant

upon request).

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(7) If the Adverse Benefit Determination is based on the Medical Necessity or Experimental or Investigational

exclusion or similar such exclusion, an explanation of the scientific or clinical judgment for the

determination applying the terms of the Plan to the Claim, or a statement that such explanation will be

provided free of charge, upon request.

(8) Identification of medical or vocational experts, whose advice was obtained on behalf of the Plan in

connection with a Claim.

If the Claimant does not understand the reason for the Adverse Benefit Determination, the Claimant should contact

the Claims Administrator at the address or telephone number printed on the Notice of Determination.

Claims Review Procedure - General

A Claimant may appeal an Adverse Benefit Determination. The Plan offers a two-level review procedure to provide

the Claimant with a full and fair review of the Adverse Benefit Determination.

The Plan will provide for a review that does not give deference to the previous Adverse Benefit Determination and

that is conducted by either an appropriate Plan representative or the Claims Administrator on the Plan’s behalf, who is

neither the individual who made the Initial Benefit Determination, nor a subordinate of that individual. The review

will take into account all comments, documents, records and other information submitted by the Claimant related to

the claim, without regard as to whether this information was submitted or considered in the Initial Benefit

Determination.

If the Adverse Benefit Determination was based in whole or in part upon medical judgment, including determinations

on whether a particular treatment, drug, or other item is Experimental and/or Investigational, or not Medically

Necessary, the Plan Administrator or its designee will consult with a health care professional who has the appropriate

training and experience in the applicable field of medicine; was not consulted in the Initial Benefit Determination;

and is not the subordinate of the initial decision-maker. The Plan may consult with vocational or other experts

regarding the Initial Benefit Determination.

The Plan Administrator will provide free of charge upon request by the Claimant, reasonable access to and copies of,

documents, records, and other information as described in Items 5 through 8 under “Notice of Adverse Benefit

Determination”.

First Level of Claims Review

The written request for review must be submitted within 180 days of the Claimant’s receipt of notice of an Adverse

Benefit Determination. The Claimant should include in the appeal letter: his or her name, ID number, group health

plan name, and a statement of why the Claimant disagrees with the Adverse Benefit Determination. The Claimant

may include any additional supporting information, even if not initially submitted with the Claim. The appeal should

be addressed to:

Employee Benefit Management Services, Inc. (EBMS)

P.O. Box 21367

Billings, Montana 59104

Attn: Claims Appeals

An appeal will not be deemed submitted until it is received by the Plan Administrator. Failure to appeal the

initial Adverse Benefit Determination within the 180 day period will render that determination final.

The first level of review will be performed by the Claims Administrator on the Plan’s behalf. The Claims

Administrator will review the information initially received and any additional information provided by the

Claimant, and determine if the Initial Benefit Determination was appropriate based upon the terms and conditions of

the Plan and other relevant information. The Claims Administrator will send a written or electronic Notice of

Determination to the Claimant within 30 days of the receipt of the appeal.

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Second Level of Claims Review

If the Claimant does not agree with the Claims Administrator’s determination from the first level review, the

Claimant may submit a second level appeal in writing within 60 days of the Claimant’s receipt of the Notice of

Determination from the first level of review, along with any additional supporting information to:

Employee Benefit Management Services, Inc. (EBMS)

P.O. Box 21367

Billings, Montana 59104

Attn: Claims Appeals

An appeal will not be deemed submitted until it is received by the Claims Administrator. Failure to appeal the

determination from the first level of review within the 60 day period will render that determination final.

The second level of review will be done by the Claims Administrator. The Claims Administrator will review the

information initially received and any additional information provided by the Claimant, and make a determination on

the appeal based upon the terms and conditions of the Plan and other relevant information. The Claims

Administrator will send a written or electronic Notice of Determination for the second level of review to the

Claimant within 30 days or the next scheduled insurance benefit committee meeting, whichever occurs later, of the

receipt of the appeal. The determination by the Claims Administrator upon review will be final, binding, and

conclusive and will be afforded the maximum deference permitted by law.

If upon review, the Adverse Benefit Determination remains the same and the Claimant still does not agree with the

determination, the Claimant has the right to bring an action for benefits. Before filing a lawsuit, the Claimant must

exhaust both levels of review as described in this section. A legal action to obtain benefits must be commenced

within one (1) year of the date of the notice of the Claims Administrator’s determination on the second level of

review.

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COORDINATION OF BENEFITS

Coordination of the benefit plans. The Plan’s Coordination of Benefits provision sets forth rules for the order of

payment of Covered Charges when two or more plans – including Medicare – are paying. The Plan has adopted the

order of benefits as set forth in the National Association of Insurance Commissioners (NAIC) Model COB Regulations,

as amended. When a Covered Person is covered by this Plan and another plan, or the Covered Person’s Spouse is

covered by this Plan and by another plan, or the couple’s Covered children are covered under two or more plans the

plans will coordinate benefits when a claim is received.

The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary and

subsequent plans will pay the balance due up to 100% of the total Allowable Charges.

Benefit plan. This provision will coordinate the medical and dental benefits of a benefit plan. The term benefit plan

means this Plan or any one of the following plans:

(1) Group or group-type plans, including franchise or blanket benefit plans.

(2) Blue Cross and Blue Shield group plans.

(3) Group practice and other group prepayment plans.

(4) Federal government plans or programs. This includes, but is not limited to Medicare and Tricare.

(5) Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that,

by its terms, does not allow coordination.

(6) Any automobile insurance, including but not limited to, No Fault Auto Insurance, by whatever name it is

called, when not prohibited by law.

(7) Any third-party liability insurance, including but not limited to, homeowners liability insurance,

umbrella insurance and premises liability insurance, whether individual or commercial, or on an insured,

uninsured, under-insured or self-insured basis.

If the Covered Person, or someone on behalf of the Covered Person, has received any compensation and/or benefits

from any third-party source, this compensation and/or benefits shall be primary and shall be coordinated with the

benefits that they may be eligible to receive through this Plan before they may receive any benefits from this Plan.

Allowable Charge(s). For a charge to be allowable it must be a Usual, Customary, and Reasonable Charge and at

least part of it must be covered under this Plan.

In the case of HMO (Health Maintenance Organization) or other in-network only plans: This Plan will not consider

any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an

HMO or network plan is primary and the Covered Person does not use an HMO or network provider, this Plan will

not consider as an Allowable Charge any charge that would have been covered by the HMO or network plan had the

Covered Person used the services of an HMO or network provider.

In the case of service type plans where services are provided as benefits, the reasonable cash value of each service

will be the Allowable Charge.

Automobile limitations. When any payments are available under vehicle insurance, the Plan shall pay excess

benefits only, without reimbursement for vehicle plan deductibles. This Plan shall always be considered the

secondary carrier regardless of the individual’s election under PIP (personal Injury protection) coverage with the auto

carrier.

Benefit plan payment order. When two or more plans provide benefits for the same Allowable Charge, benefit

payment will follow these rules:

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(A)

(B)

Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision

will be considered after those without one.

Plans with a coordination provision will pay their benefits up to the Allowable Charge.

The first rule that describes which plan is primary is the rule that applies:

(1) The benefits of the plan which covers the person directly (that is, as a Member/Employee,

Retiree, or subscriber) (“Plan A”) are determined before those of the plan which covers the

person as a Dependent (“Plan B”).

For Qualified Beneficiaries, coordination is determined based on the person’s status prior to the

Qualifying Event.

Special rule. If: (i) the person covered directly is a Medicare beneficiary, and (ii) Medicare is

secondary to Plan B, and (iii) Medicare is primary to Plan A (for example, if the person is

retired), THEN Plan B will pay first.

(2) Unless there is a court decree stating otherwise, when a child is covered as a Dependent by

more than one plan the order of benefits is determined as follows:

When a child is covered as a Dependent and the parents are married or living together, these

rules will apply:

• The benefits of the benefit plan of the parent whose birthday falls earlier in a year are

determined before those of the benefit plan of the parent whose birthday falls later in that

year;

• If both parents have the same birthday, the benefits of the benefit plan which has covered

the parent for the longer time are determined before those of the benefit plan which covers

the other parent.

When a child’s parents are divorced, legally separated or not living together, whether or not

they have ever been married, these rules will apply:

• A court decree may state which parent is financially responsible for medical and dental

benefits of the child. In this case, the benefit plan of that parent will be considered before

other plans that cover the child as a Dependent. This rule applies beginning the first of the

month after the plan is given notice of the court decree.

• A court decree may state both parents will be responsible for the Dependent child’s health

care expenses. In this case, the plans covering the child shall follow order of benefit

determination rules outlined above when the parents are married or living together (as

detailed above);

• If the specific terms of the court decree state that the parents shall share joint custody,

without stating that one of the parents is responsible for the health care expenses of the

child, the plans covering the child shall follow the order of benefit determination rules

outlined above when a child is covered as a Dependent and the parents are married or living

together.

If there is no court decree allocating responsibility for the Dependent child’s health care

expenses, the order of benefits are as follows:

1 st The plan covering the custodial parent,

2 nd The plan covering the spouse of the custodial parent,

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3 rd The plan covering the non-custodial parent, and

4 th The plan covering the spouse of the non-custodial parent.

(3) The benefits of a benefit plan which covers a person as a Member/Employee who is neither laid

off nor retired are determined before those of a benefit plan which covers that person as a

laid-off or Retired Member/Employee. The benefits of a benefit plan which covers a person as a

Dependent of a Member/Employee who is neither laid off nor retired are determined before

those of a benefit plan which covers a person as a Dependent of a laid off or Retired

Member/Employee. If the other benefit plan does not have this rule, and if, as a result, the plans

do not agree on the order of benefits, this rule does not apply.

(4) The benefits of a benefit plan which covers a person as a Member/Employee who is neither laid

off nor retired or a Dependent of a Member/Employee who is neither laid off nor retired are

determined before those of a plan which covers the person as a COBRA beneficiary. This rule

does not apply if rule #1 can be used to determine the order of benefits.

(5) If there is still a conflict after these rules have been applied, the benefit plan which has covered

the patient for the longer time will be considered first. When there is a conflict in coordination

of benefit rules, the Plan will never pay more than 50% of Allowable Charges when paying

secondary.

(C)

(D)

(E)

Medicare will pay primary, secondary or last to the extent stated in federal law (see the Effect of

Medicare provision in the section below). When Medicare is to be the primary payer, this Plan will base

its payment upon benefits that would have been paid by Medicare under Parts A and B, regardless of

whether or not the person was enrolled under both of these parts. The Plan reserves the right to

coordinate benefits with respect to Medicare Part D.

If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will

pay first and this Plan will pay second.

The Plan will pay primary to Tricare to the extent required by federal law.

Claims Determination Period. Benefits will be coordinated on a Calendar Year basis. This is called the Claims

Determination Period. This does not include any part of a year during which the Covered Person is not covered under

this Plan or any date before this section or any similar provision takes effect.

Right to receive or release necessary information. To make this provision work, this Plan may give or obtain

needed information from another insurer or any other organization or person. This information may be given or

obtained without the consent of or notice to any other person. A Covered Person will give this Plan the information it

asks for about other plans and their payment of Allowable Charges.

Facility of payment. This Plan may repay other plans for benefits paid that the Plan Administrator determines it

should have paid. That repayment will count as a valid payment under this Plan.

Right of recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may

recover the amount paid from the other benefit plan or the Covered Person. That repayment will count as a valid

payment under the other benefit plan.

Further, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case, this Plan

may recover the amount of the overpayment from the source to which it was paid.

All Individuals Eligible for Medicare. Covered Persons should be certain to enroll in Medicare Part A & B

coverage in a timely manner to assure maximum coverage. Contact the Social Security Administration office to enroll

for Medicare. If this Plan is secondary, benefits under this Plan will be coordinated with the dollar amount that

Medicare will pay, subject to the rules and regulations specified by federal law.

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Medicare and COBRA. For most COBRA beneficiaries, Medicare rules state that Medicare will be primary to

COBRA continuation coverage, and this would apply to this Plan’s COBRA Continuation Coverage provision.

Exception to Medicaid. The Plan shall not take into consideration the fact that an individual is eligible for or is

provided medical assistance through Medicaid when enrolling an individual in the Plan or making a determination

about the payments for benefits received by a Covered Person under the Plan.

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THIRD PARTY RECOVERY PROVISION

Defined Terms

"Covered Person" means anyone covered under the Plan, including but not limited to minor dependents and deceased

Covered Persons. Covered Person shall include the parents, trustee, guardian, heir, personal representative or other

representative of a Covered Person, regardless of applicable law and whether or not such representative has access or

control of the Recovery.

"Recover," "Recovered," "Recovery" means all monies recovered by way of judgment, settlement, reimbursement, or

otherwise to compensate for any loss related to any Injury, Sickness, condition, and/or accident where a Third Party is

or may be responsible. "Recovery" includes, but is not limited to, recoveries for medical or dental expenses,

attorneys' fees, costs and expenses, pain and suffering, loss of consortium, wrongful death, wages and/or any other

recovery of any form of damages or compensation whatsoever.

"Subrogation" means the Plan's right to exercise the Covered Person’s rights to Recover or pursue Recovery from a

Third Party who is liable to the Covered Person for expenses for which the Plan has paid or may agree to pay

benefits.

"Third Party" means any third party including but not limited to another person, any business entity, insurance policy

or any other policy or plan, including but not limited to uninsured or underinsured coverage, self-insured coverage,

no-fault coverage, automobile coverage, premises liability (homeowners or business), umbrella policy.

Right to Reimbursement

This provision applies when the Covered Person incurs medical or dental expenses due to an Injury, Sickness,

condition, and/or accident which may be caused by the act or omission of a Third Party or a Third Party may be

responsible for payment. In such circumstances, the Covered Person may have a claim against a Third Party for

payment of such expenses. To the extent the Plan paid benefits on the Covered Person’s behalf, the Covered Person

agrees that the Plan has an equitable lien on any Recovery whether or not such Recovery(s) is designated as payment

for such expenses. This lien shall remain in effect until the Plan is repaid in full.

The Covered Person, and/or anyone on his or her behalf, agrees to hold in trust for the benefit of the Plan, that portion

of any Recovery received or that may be received from a Third Party and to which the Plan is entitled for

reimbursement of benefits paid by the Plan on the Covered Person’s behalf. The Covered Person shall promptly

reimburse the Plan out of such Recovery, in first priority for the full amount of the Plan’s lien. The Covered Person

will reimburse the Plan first, even if the Covered Person has not been fully compensated or “made whole” and/or the

Recovery is called something other than a Recovery for healthcare, medical and/or dental expenses.

The Plan will not pay or be responsible for attorney fees and/or costs of recovery associated with a Covered Person

pursuing a claim against a Third Party, unless the Plan agrees in writing to such a reduction in its equitable lien, or

subject to the terms of a court order.

Right to Subrogation

This provision applies when the Covered Person incurs medical or dental expenses due to an Injury, Sickness,

condition, and/or accident which may be caused by the act or omission of a Third Party or a Third Party may be

responsible for payment. In such circumstances, the Covered Person may have a claim against a Third Party for

payment of such expenses.

The Covered Person agrees that the Plan is subrogated to any and all claims, causes of action or rights that the

Covered Person may have now or in the future against a Third Party who has or may have caused, contributed

aggravated, and or be responsible for the Covered Person’s Injury, Sickness, condition, and/or accident to the extent

the Plan has paid benefits or has agreed to pay benefits. The Covered Person further agrees that the Plan is subrogated

to any and all claims or rights that the Covered Person may have against any Recovery, including the Covered

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Person’s rights under the Plan to bring an action to clarify his rights under the Plan. The Plan may assert this Right of

Subrogation independently of the Covered Person. The Plan is not obligated to pursue this right independently or on

behalf of the Covered Person, but may choose to exercise this right, in its sole discretion.

Provisions Applicable to Both the Right to Reimbursement and Right to Subrogation

The Covered Person automatically assigns to the Plan any and all rights he or she has or may have against any Third

Party to the full extent of the Plan’s equitable lien. The Covered Person agrees to:

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Cooperate fully with the Plan and its agents, regarding the Plan's rights under this section;

Advise the Plan of any right or potential right to reimbursement and/or subrogation on the Plan’s behalf;

Provide to the Plan in a timely manner any and all facts, documents, papers, information or other data

reasonably related to the Covered Person’s Injury, Sickness, condition, and/or accident, including any efforts

by another individual to Recover on the Covered Person’s behalf;

Execute all assignments, liens, or other documents that the Plan or its agents may request to protect the

Plan’s rights under this section;

Obtain the Plan’s consent before releasing a Third Party from liability for payment of expenses related to the

Covered Person’s Injury, Sickness, condition, and/or accident;

Hold in trust that portion of any Recovery received by the Covered Person or on the Covered Person’s behalf

equal to the Plan’s equitable lien until such time as the Plan is repaid in full;

Agree not to impair, impede or prejudice in any way, the rights of the Plan under this section; and

Do whatever else the Plan deems reasonably necessary to secure the Plan's rights under this section.

The Plan may take one or more of the following actions to enforce its rights under this section:

(a)

(b)

(c)

(d)

(e)

The Plan may require the Covered Person as a condition of paying benefits for the Covered Person’s Injury,

Sickness, condition, or accident, to execute documentation acknowledging the Plan’s rights under this

section;

The Plan may withhold payment of benefits to the extent of any Recovery received by or on behalf of a

Covered Person;

The Plan may, to the extent of any benefits paid by the Plan, exercise its Right of Reimbursement against any

Recovery received, or that will be received, by or on behalf of Covered Person;

The Plan may, to the extent of any benefits paid by the Plan, exercise its Right of Subrogation directly

against a Third Party who is or may be responsible; or

The Plan may, to the extent of any benefits paid by the Plan which have not otherwise been reimbursed to the

Plan, offset any future benefits otherwise payable under the Plan to the Covered Person or on the Covered

Person’s behalf.

The Plan Administrator is vested with full discretionary authority to interpret and apply the provisions of this section.

In addition, the Plan Administrator is vested with the discretionary authority to waive or compromise any of the

Plan’s rights under this section. Any decision of the Plan Administrator made in good faith will be final and binding.

The Plan Administrator is authorized to adopt such procedures as deemed necessary and appropriate to administrate

the Plan’s rights under this section.

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COBRA CONTINUATION COVERAGE

Introduction

The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget

Reconciliation Act of 1985, as amended (“COBRA”). COBRA Continuation Coverage can become available to you

when you otherwise would lose your group health coverage. It also can become available to other members of your

family who are covered under the Plan when they otherwise would lose their group health coverage. The entire cost

(plus a reasonable administration fee) must be paid by the Covered Employee (or former Employee), Qualified

Beneficiary, or any representative acting on behalf thereof. Coverage will end in certain instances, including, but not

limited to, if you or your Dependents fail to make timely payment of premiums. You should check with your

Employer to see if COBRA applies to you and your Dependents.

What is COBRA Continuation Coverage

“COBRA Continuation Coverage” is a continuation of Plan coverage when coverage otherwise would end because of

a life event known as a “Qualifying Event.” Life insurance, accidental death and dismemberment benefits and

weekly income or long-term disability benefits (if a part of your Employer’s plan) are not considered for continuation

under COBRA.

What is a Qualifying Event

Specific Qualifying Events are listed below. After a Qualifying Event, COBRA Continuation Coverage must be

offered to each person who is a “Qualified Beneficiary.” You, your Spouse, and your Dependent children could

become Qualified Beneficiaries if coverage under the Plan is lost because of the Qualifying Event. A domestic

partner is not a Qualified Beneficiary.

If you are a Covered Employee (meaning that you are an Employee and are covered under the Plan), you will become

a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events:

• Your hours of employment are reduced; or

• Your employment ends for any reason other than your gross misconduct.

If you are the Spouse of a Covered Employee, you will become a Qualified Beneficiary if you lose your coverage

under the Plan due to one of the following Qualifying Events:

• Your Spouse dies;

• Your Spouse’s hours of employment are reduced;

• Your Spouse’s employment ends for any reason other than his or her gross misconduct;

• Your Spouse becomes entitled to Medicare benefits (under Part A, Part B, or both);

• You become divorced or legally separated from your Spouse; or

• In certain circumstances, you are no longer eligible for coverage under the Plan.

Note: Medicare entitlement means that you are eligible for and enrolled in Medicare.

Your Dependent children will become Qualified Beneficiaries if they lose coverage under the Plan due to one of the

following Qualifying Events:

• The parent-Covered Employee dies;

• The parent-Covered Employee’s hours of employment are reduced;

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• The parent-Covered Employee’s employment ends for any reason other than his or her gross misconduct;

• The parent-Covered Employee becomes entitled to Medicare benefits (Part A, Part B, or both);

• The parents become divorced or legally separated; or

• The child is no longer eligible for coverage under the plan as a “Dependent child.”

If this Plan provides retiree health coverage, sometimes, filing a proceeding in bankruptcy under Title 11 of the

United States Code can be a Qualifying Event. If a proceeding in bankruptcy is filed with respect to the Employer,

and that bankruptcy results in the loss of coverage of any retired Employee covered under the Plan, the retired

Employee will become a Qualified Beneficiary with respect to the bankruptcy. The retired Employee’s Spouse,

surviving Spouse, and Dependent children also will become Qualified Beneficiaries if bankruptcy results in the loss

of their coverage under the Plan.

The Employer must give notice of some Qualifying Events

When the Qualifying Event is the end of employment, reduction of hours of employment, death of the Covered

Employee, commencement of proceeding in bankruptcy with respect to the Employer, or the Covered Employee’s

becoming entitled to Medicare benefits (under Part A, Part B, or both), the Plan Administrator must be notified of the

Qualifying Event.

You must give notice of some Qualifying Events

Each Covered Employee or Qualified Beneficiary is responsible for providing the Plan Administrator with the

following notices, in writing, either by U.S. First Class Mail or hand delivery:

1) Notice of the occurrence of a Qualifying Event that is a divorce or legal separation of a Covered Employee

(or former Employee) from his or her Spouse;

2) Notice of the occurrence of a Qualifying Event that is an individual’s ceasing to be eligible as a Dependent

child under the terms of the Plan;

3) Notice of the occurrence of a second Qualifying Event after a Qualified Beneficiary has become entitled to

COBRA Continuation Coverage with a maximum duration of 18 (or 29) months;

4) Notice that a Qualified Beneficiary entitled to receive Continuation Coverage with a maximum duration of

18 months has been determined by the Social Security Administration (“SSA”) to be disabled at any time

during the first 60 days of Continuation Coverage; and

5) Notice that a Qualified Beneficiary, with respect to whom a notice described in (4) above has been provided,

has subsequently been determined by the SSA to no longer be disabled.

The Plan Administrator is:

El Paso County Government

2880 International Circle

Colorado Springs, Colorado 80910

(719) 520-7420

A form of notice is available, free of charge, from the COBRA Administrator and must be used when providing the

notice.

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Deadline for providing the notice

For Qualifying Events described in (1), (2) or (3) above, the notice must be furnished by the date that is 60 days after

the latest of:

• The date on which the relevant Qualifying Event occurs;

• The date on which the Qualified Beneficiary loses (or would lose) coverage under the Plan as a result of the

Qualifying Event; or

• The date on which the Qualified Beneficiary is informed, through the furnishing of the Plan's SPD or the general

notice, of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the

Plan Administrator.

For the disability determination described in (4) above, the notice must be furnished by the date that is 60 days after

the latest of:

• The date of the disability determination by the SSA;

• The date on which a Qualifying Event occurs;

• The date on which the Qualified Beneficiary loses (or would lose) coverage under the Plan as a result of the

Qualifying Event; or

• The date on which the Qualified Beneficiary is informed, through the furnishing of the Plan’s SPD or the general

notice, of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the

Plan Administrator.

In any event, this notice must be furnished before the end of the first 18 months of Continuation Coverage.

For a change in disability status described in (5) above, the notice must be furnished by the date that is 30 days after

the later of:

• The date of the final determination by the SSA that the Qualified Beneficiary is no longer disabled; or

• The date on which the Qualified Beneficiary is informed, through the furnishing of the Plan's SPD or the general

notice, of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the

Plan Administrator.

The notice must be postmarked (if mailed), or received by the Plan Administrator (if hand delivered), by the deadline

set forth above. If the notice is late, the opportunity to elect or extend COBRA Continuation Coverage is lost, and if

you are electing COBRA Continuation Coverage, your coverage under the Plan will terminate on the last date for

which you are eligible under the terms of the Plan, or if you are extending COBRA Continuation Coverage, such

Coverage will end on the last day of the initial 18-month COBRA coverage period.

Who can provide the notice

Any individual who is the Covered Employee (or former Employee), a Qualified Beneficiary with respect to the

Qualifying Event, or any representative acting on behalf of the Covered Employee (or former Employee) or Qualified

Beneficiary, may provide the notice, and the provision of notice by one individual shall satisfy any responsibility to

provide notice on behalf of all related Qualified Beneficiaries with respect to the Qualifying Event.

Required contents of the notice.

The notice must contain the following information:

• Name and address of the Covered Employee or former Employee;

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• If you already are receiving COBRA Continuation Coverage and wish to extend the maximum coverage period,

identification of the initial Qualifying Event and its date of occurrence;

• A description of the Qualifying Event (for example, divorce, legal separation, cessation of Dependent status,

entitlement to Medicare by the Covered Employee or former Employee, death of the Covered Employee or

former Employee, disability of a Qualified Beneficiary or loss of disability status);

• In the case of a Qualifying Event that is divorce or legal separation, name(s) and address(es) of Spouse and

Dependent child(ren) covered under the Plan, date of divorce or legal separation, and a copy of the decree of

divorce or legal separation;

• In the case of a Qualifying Event that is Medicare entitlement of the Covered Employee or former Employee (or

in certain circumstances, the Spouse), date of entitlement, and name(s) and address(es) of Spouse and Dependent

child(ren) covered under the Plan;

• In the case of a Qualifying Event that is a Dependent child’s cessation of Dependent status under the Plan, name

and address of the child, reason the child ceased to be an eligible Dependent (for example, attained limiting age,

lost student status, married or other);

• In the case of a Qualifying Event that is the death of the Covered Employee or former Employee, the date of

death, and name(s) and address(es) of Spouse and Dependent child(ren) covered under the Plan;

• In the case of a Qualifying Event that is disability of a Qualified Beneficiary, name and address of the disabled

Qualified Beneficiary, name(s) and address(es) of other family members covered under the Plan, the date the

disability began, the date of the SSA’s determination, and a copy of the SSA’s Notice of Award letter;

• In the case of a Qualifying Event that is loss of disability status, name and address of the Qualified Beneficiary

who is no longer disabled, name(s) and address(es) of other family members covered under the Plan, the date the

disability ended and the date of the SSA’s determination; and

• A certification that the information is true and correct, a signature and date.

If you cannot provide a copy of the decree of divorce, legal separation or the SSA’s Notice of Award letter by the

deadline for providing the notice, complete and provide the notice, as instructed, by the deadline and submit the copy

of the decree of divorce, legal separation, or the SSA’s Notice of Award letter within 30 days after the deadline. The

notice will be timely if you do so. However, no COBRA Continuation Coverage, or extension of such Coverage, will

be available until the copy of the decree of divorce or legal separation, or the SSA’s Notice of Award letter is

provided.

If the notice does not contain all of the required information, the Plan Administrator may request additional

information. If the individual fails to provide such information within the time period specified by the Plan

Administrator in the request, the Plan Administrator may reject the notice if it does not contain enough information

for the Plan Administrator to identify the plan, the Covered Employee (or former Employee), the Qualified

Beneficiaries, the Qualifying Event or disability, and the date on which the Qualifying Event, if any, occurred.

Electing COBRA Continuation Coverage

Complete instructions on how to elect COBRA Continuation Coverage will be provided by the COBRA

Administrator within 14 days of receiving the notice of your Qualifying Event. You then have 60 days in which to

elect COBRA Continuation Coverage. The 60-day period is measured from the later of the date coverage terminates

or the date of the notice containing the instructions. If COBRA Continuation Coverage is not elected in that 60-day

period, then the right to elect it ceases.

Each Qualified Beneficiary will have an independent right to elect COBRA Continuation Coverage. Covered

Employees may elect COBRA Continuation Coverage on behalf of their Spouses, and parents may elect COBRA

Continuation Coverage on behalf of their children.

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In the event that the COBRA Administrator determines that the individual is not entitled to COBRA Continuation

Coverage, the COBRA Administrator will provide to the individual an explanation as to why he or she is not entitled

to COBRA Continuation Coverage.

How long does COBRA Continuation Coverage last

COBRA Continuation Coverage will be available up to the maximum time period shown below. Generally, multiple

Qualifying Events which may be combined under COBRA will not continue coverage for more than 36 months

beyond the date of the original Qualifying Event. However, if, pursuant to the Plan, the first Qualifying Event is the

Covered Employee’s entitlement to Medicare benefits, followed by termination or reduction of hours, then the

maximum coverage period for Qualified Beneficiaries other than the Covered Employee ends on the later of (i) 36

months after the date the Covered Employee became entitled to Medicare benefits, and (ii) 18 months (or 29 months

if there is a disability extension) after the date of the termination or reduction of hours. For all other Qualifying

Events, the continuation period is measured from the date of the Qualifying Event, not the date of loss of coverage.

If, pursuant to the Plan, the Qualifying Event is the death of the Covered Employee (or former Employee), the

Covered Employee’s (or former Employee’s) becoming entitled to Medicare benefits (under Part A, Part B, or both),

your divorce or legal separation, or a Dependent child’s losing eligibility as a Dependent child, COBRA Continuation

Coverage lasts for up to a total of 36 months.

If the Qualifying Event is the end of employment or reduction of the Covered Employee’s hours of employment, and

the Covered Employee became entitled to Medicare benefits less than 18 months before the Qualifying Event,

COBRA Continuation Coverage for Qualified Beneficiaries other than the Covered Employee lasts until 36 months

after the date of Medicare entitlement. For example, if a Covered Employee becomes entitled to Medicare 8 months

before the date on which his employment terminates, COBRA Continuation Coverage for his Spouse and children can

last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the

Qualifying Event (36 months minus 8 months).

Otherwise, when the Qualifying Event is the end of employment (for reasons other than gross misconduct) or

reduction of the Covered Employee’s hours of employment, COBRA Continuation Coverage generally lasts for only

up to a total of 18 months. There are two ways in which this 18-month period of COBRA Continuation Coverage can

be extended.

Disability extension of 18-month period of COBRA Continuation Coverage

If you or anyone in your family covered under the Plan is determined by the SSA to be disabled and you notify the

Plan Administrator as set forth above, you and your entire family may be entitled to receive up to an additional 11

months of COBRA Continuation Coverage, for a total maximum of 29 months. The disability would have to have

started at some time before the 60th day of COBRA Continuation Coverage and must last at least until the end of the

18-month period of COBRA Continuation Coverage. An extra fee will be charged for this extended COBRA

Continuation Coverage.

Second Qualifying Event extension of 18-month period of COBRA Continuation Coverage

If your family experiences another Qualifying Event while receiving 18 months of COBRA Continuation Coverage,

the Spouse and Dependent children in your family can get up to 18 additional months of COBRA Continuation

Coverage, for a maximum of 36 months, if notice of the second Qualifying Event properly is given to the Plan as set

forth above. This extension may be available to the Spouse and any Dependent children receiving COBRA

Continuation Coverage if the Covered Employee or former Employee dies, becomes entitled to Medicare benefits

(under Part A, Part B, or both), or gets divorced or legally separated, or if the Dependent child stops being eligible

under the Plan as a Dependent child, but only if the event would have caused the Spouse or Dependent child to lose

coverage under the Plan had the first Qualifying Event not occurred.

Does COBRA Continuation Coverage ever end earlier than the maximum periods above

COBRA Continuation Coverage also may end before the end of the maximum period on the earliest of the following

dates:

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• The date your Employer ceases to provide a group health plan to any Employee;

• The date on which coverage ceases by reason of the Qualified Beneficiary’s failure to make timely payment of

any required premium;

• The date that the Qualified Beneficiary first becomes, after the date of election, covered under any other group

health plan (as an Employee or otherwise), or entitled to either Medicare Part A or Part B (whichever comes

first), except as stated under COBRA’s special bankruptcy rules. However, a Qualified Beneficiary who becomes

covered under a group health plan which has a pre-existing condition limit must be allowed to continue COBRA

Continuation Coverage for the length of a pre-existing condition or to the COBRA maximum time period, if less;

• The first day of the month that begins more than 30 days after the date of the SSA’s determination that the

Qualified Beneficiary is no longer disabled, but in no event before the end of the maximum coverage period that

applied without taking into consideration the disability extension; or

• On the same basis that the Plan can terminate for cause the coverage of a similarly situated non-COBRA

participant.

Payment for COBRA Continuation Coverage

Once COBRA Continuation Coverage is elected, you must pay for the cost of the initial period of coverage within 45

days. Payments then are due on the first day of each month to continue coverage for that month. If a payment is not

received and/or post-marked within 30 days of the due date, COBRA Continuation Coverage will be canceled and

will not be reinstated.

Two provisions under the Trade Act affect the benefits received under COBRA. First, certain eligible individuals who

lose their jobs due to international trade agreements may receive a 65% tax credit for premiums paid for certain types

of health insurance, including COBRA premiums. Second, eligible individuals under the Trade Act who do not elect

COBRA Continuation Coverage within the election period will be allowed an additional 60-day period to elect

COBRA Continuation Coverage. If the Qualified Beneficiary elects COBRA Continuation Coverage during this

second election period, the coverage period will run from the beginning date of the second election period. You

should consult the Plan Administrator if you believe the Trade Act applies to you.

Additional Information

Additional information about the Plan and COBRA Continuation Coverage is available from the Plan Administrator

and COBRA Administrator:

Plan Administrator

COBRA Administrator

El Paso County Government

Employee Benefit Management Services, Inc.

2880 International Circle PO Box 21367

Colorado Springs, CO 80910 Billings, Montana 59104

(719) 520-7420 (406) 245-3575 or (800) 777-3575

For more information about your rights under COBRA and other laws affecting group health plans, contact the U.S.

Department of Labor’s Employee Benefits Security Administration (EBSA) at 1 (866) 444-3272 or visit the EBSA

website at www.dol.gov/ebsa.

Current Addresses

In order to protect your family’s rights, you should keep the Plan Administrator (who is identified above) informed of

any changes in the addresses of family members.

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RESPONSIBILITIES FOR PLAN ADMINISTRATION

PLAN ADMINISTRATOR. El Paso County is the benefit plan of El Paso County, the Plan Administrator, also

called the Plan Sponsor. An individual may be appointed by El Paso County to be Plan Administrator and serve at the

convenience of the Employer. If the Plan Administrator resigns, dies or is otherwise removed from the position, El

Paso County shall appoint a new Plan Administrator as soon as reasonably possible.

The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies,

interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have

maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make

determinations regarding issues which relate to eligibility for benefits, to decide disputes which may arise relative to a

Plan Participant's rights, and to decide questions of Plan interpretation and those of fact relating to the Plan. The

decisions of the Plan Administrator will be final and binding on all interested parties.

DUTIES OF THE PLAN ADMINISTRATOR.

(1) To administer the Plan in accordance with its terms.

(2) To interpret the Plan, including the right to remedy possible ambiguities, inconsistencies or omissions.

(3) To decide disputes which may arise relative to a Plan Participant's rights.

(4) To prescribe procedures for filing a claim for benefits and to review claim denials.

(5) To keep and maintain the Plan documents and all other records pertaining to the Plan.

(6) To appoint a Claims Administrator to pay claims.

(7) To delegate to any person or entity such powers, duties and responsibilities as it deems appropriate.

PLAN ADMINISTRATOR COMPENSATION. The Plan Administrator serves without compensation; however,

all expenses for plan administration, including compensation for hired services, will be paid by the Plan.

CLAIMS ADMINISTRATOR IS NOT A FIDUCIARY. A Claims Administrator is not a fiduciary under the Plan

by virtue of paying claims in accordance with the Plan's rules as established by the Plan Administrator.

The cost of the Plan is funded as follows:

FUNDING THE PLAN AND PAYMENT OF BENEFITS

For Employee and Dependent Coverage: Funding is derived from the funds of the Employer and contributions

made by the covered Employees.

The level of any Employee contributions will be set by the Plan Administrator. These Employee contributions will be

used in funding the cost of the Plan as soon as practicable after they have been received from the Employee or

withheld from the Employee's pay through payroll deduction.

Benefits are paid directly from the Plan through the Claims Administrator.

PLAN IS NOT AN EMPLOYMENT CONTRACT

The Plan is not to be construed as a contract for or of employment.

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CLERICAL ERROR

Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a

delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly

terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.

If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right

to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect

amount of money. In the case of a Plan Participant, if it is requested, the amount of overpayment will be deducted

from future benefits payable.

STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (THE

“PRIVACY STANDARDS”) ISSUES PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT OF 1996, AS AMENDED (HIPAA)

Disclosure of Summary Health Information to the Plan Sponsor

In accordance with the Privacy Standards, the Plan may disclose Summary Health Information to the Plan Sponsor, if the

Plan Sponsor requests the Summary Health Information for the purpose of (a) obtaining premium bids from health plans

for providing health insurance coverage under this Plan or (b) modifying, amending or terminating the Plan.

“Summary Health Information” may be individually identifiable health information and it summarizes the claims history,

claims expenses or the type of claims experienced by individuals in the plan, but it excludes all identifiers that must be

removed for the information to be de-identified, except that it may contain geographic information to the extent that it is

aggregated by five-digit zip code.

Disclosure of Protected Health Information (PHI) to the Plan Sponsor for Plan Administration Purposes

“Protected Health Information” (PHI) means individually identifiable health information, created or received by a

health care provider, health plan, employer, or health care clearinghouse; and relates to the past, present, or future

physical or mental health condition of an individual; the provision of health care to an individual; or the past, present,

or future payment for the provision of health care to an individual; and is transmitted or maintained in any form or

medium.

In order that the Plan Sponsor may receive and use PHI for Plan Administration purposes, the Plan Sponsor agrees to:

(1) Not use or further disclose PHI other than as permitted or required by the Plan Documents or as Required by

Law (as defined in the Privacy Standards);

(2) Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the

Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI;

(3) Not use or disclose PHI for employment-related actions and decisions or in connection with any other

benefit or employee benefit plan of the Plan Sponsor, except pursuant to an authorization which meets the

requirements of the Privacy Standards;

(4) Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of

which the Plan Sponsor becomes aware;

(5) Make available PHI in accordance with Section 164.524 of the Privacy Standards (45 CFR 164.524);

(6) Make available PHI for amendment and incorporate any amendments to PHI in accordance with Section

164.526 of the Privacy Standards (45 CFR 164.526);

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(7) Make available the information required to provide an accounting of disclosures in accordance with Section

164.528 of the Privacy Standards (45 CFR 164.528);

(8) Make its internal practices, books and records relating to the use and disclosure of PHI received from the

Plan available to the Secretary of the U.S. Department of Health and Human Services (“HHS”), or any other

officer or employee of HHS to whom the authority involved has been delegated, for purposes of determining

compliance by the Plan with Part 164, Subpart E, of the Privacy Standards (45 CFR 164.500 et seq);

(9) If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form

and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made,

except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes

that make the return or destruction of the PHI infeasible; and

(10) Ensure that adequate separation between the Plan and the Plan Sponsor, as required in Section

164.504(f)(2)(iii) of the Privacy Standards (45 CFR 164.504(f)(2)(iii)), is established as follows:

(a)

The following employees, or classes of employees, or other persons under control of the Plan

Sponsor, shall be given access to the PHI to be disclosed:

Director of Employee Benefits and Compensation

Budget Analyst

Benefits Division Manager

Benefits Administration Assistant

Employee Benefits Tech

(b)

(c)

The access to and use of PHI by the individuals described in subsection (a) above shall be restricted

to the Plan Administration functions that the Plan Sponsor performs for the Plan.

In the event any of the individuals described in subsection (a) above do not comply with the

provisions of the Plan Documents relating to use and disclosure of PHI, the Plan Administrator shall

impose reasonable sanctions as necessary, in its discretion, to ensure that no further non-compliance

occurs. Such sanctions shall be imposed progressively (for example, an oral warning, a written

warning, time off without pay and termination), if appropriate, and shall be imposed so that they are

commensurate with the severity of the violation.

"Plan Administration" activities are limited to activities that would meet the definition of payment

or health care operations, but do not include functions to modify, amend or terminate the Plan or

solicit bids from prospective issuers. "Plan Administration" functions include quality assurance,

claims processing, auditing, monitoring and management of carve-out plans, such as vision and

dental. It does not include any employment-related functions or functions in connection with any

other benefit or benefit plans.

The Plan shall disclose PHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that (a) the Plan

Documents have been amended to incorporate the above provisions and (b) the Plan Sponsor agrees to comply with such

provisions.

Disclosure of Certain Enrollment Information to the Plan Sponsor

Pursuant to Section 164.504(f)(1)(iii) of the Privacy Standards (45 CFR 164.504(f)(1)(iii)), the Plan may disclose to

the Plan Sponsor information on whether an individual is participating in the Plan or is enrolled in or has disenrolled

from a health insurance issuer or health maintenance organization offered by the Plan to the Plan Sponsor.

Disclosure of PHI to Obtain Stop-loss or Excess Loss Coverage

The Plan Sponsor hereby authorizes and directs the Plan, through the Plan Administrator or the Claims Administrator, to

disclose PHI to stop-loss carriers, excess loss carriers or managing general underwriters (MGUs) for underwriting and

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other purposes in order to obtain and maintain stop-loss or excess loss coverage related to benefit claims under the Plan.

Such disclosures shall be made in accordance with the Privacy Standards and any applicable Business Associate

Agreement(s).

Other Disclosures and Uses of PHI

With respect to all other uses and disclosures of PHI, the Plan shall comply with the Privacy Standards.

STANDARDS FOR SECURITY OF ELECTRONIC PROTECTED HEALTH INFORMATION (THE

“PRIVACY STANDARDS”) ISSUES PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT OF 1996, AS AMENDED (HIPAA)

Disclosure of Electronic Protected Health Information (“Electronic PHI”) to the Plan Sponsor for Plan

Administration Functions

To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions (as defined in 45

CFR § 164.504(a)), the Plan Sponsor agrees to:

(a)

Implement administrative, physical, and technical safeguards that reasonably and appropriately

protect the confidentiality, integrity, and availability of the Electronic PHI that it creates, receives,

maintains, or transmits on behalf of the Plan;

(b) Ensure that adequate separation between the Plan and the Plan Sponsor, as required in 45 CFR §

164.504(f)(2)(iii), is supported by reasonable and appropriate security measures.

(c)

(d)

Ensure that any agent, including a subcontractor, to whom the Plan Sponsor provides Electronic PHI

created, received, maintained, or transmitted on behalf of the Plan, agrees to implement reasonable

and appropriate security measures to protect the Electronic PHI; and

Report to the Plan any security incident of which it becomes aware.

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GENERAL PLAN INFORMATION

TYPE OF ADMINISTRATION

The Plan is a self-funded group health Plan and the administration is provided through a Third Party Claims

Administrator. The funding for the benefits is derived from the funds of the Employer and contributions made by

covered Employees. The Plan is not insured.

PLAN NAME

El Paso County

TAX ID NUMBER: 84-6000764

PLAN EFFECTIVE DATE: January 1, 2002

PLAN YEAR ENDS: December 31st

EMPLOYER INFORMATION

El Paso County

2880 International Circle

Colorado Springs, Colorado 80910

(719) 520-7420

PLAN ADMINISTRATOR

El Paso County

2880 International Circle

Colorado Springs, Colorado 80910

(719) 520-7420

CLAIMS ADMINISTRATOR

Employee Benefit Management Services, Inc.

P.O. Box 21367

Billings, Montana 59102

(406) 245-3575 or (800) 777-3575

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Plan Name:

El Paso County

Plan Option: Standard Medical EPO

Effective Date: January 1, 2002

Restatement Date: January 1, 2011

Revision Date: January 1, 2013

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